Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring)

Policy ID: M-13-047

Section: Diagnostic Medical

Effective Date: September 01, 2019

Revised Date: October 03, 2023

Revision Effective Date: October 01, 2023

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

Description

Intraoperative neurophysiologic monitoring (IONM) describes a variety of procedures that have been used to monitor the integrity of neural pathways during high-risk neurosurgical, orthopedic, and vascular surgeries.

Criteria

IONM, includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography (EMG) of cranial nerves, electroencephalogram (EEG), and electrocorticography (ECoG), may be considered medically necessary

When performed by an operator who is certified by theAmerican Board of Medical Specialties (ABMS); and
Monitoring only one (1) procedure at a time; and
For ANY of the following procedures:
- Aortic arch, its branch vessels, or thoracic aorta surgery, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia; or
- Aortic procedures, distal, where there is risk of ischemia to spinal cord; or
- Arteriovenous malformations (AVMs), surgery or embolization for intracranial AVMs; or
- Basal ganglia movement disorders; or
- Brain, deep stimulation; or
- Brain, resection of epileptogenic tissue or tumor; or
- Brain, resection of tissue close to the eloquent brain cortex and requiring brain mapping; or
- Brain surgery as a result of traumatic injury; or
- Bronchial artery arteriovenous malformations or tumors, embolization of; or
- Carotid artery arteriography, during which there is a test occlusion of the carotid artery; or
- Cerebral vascular aneurysms; or
- Circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., coronary artery bypass grafting (CABG), ventricular aneurysms); or
- Cranial nerve protection during:
  - Resection of tumors involving the cranial nerves; or
  - Cavernous sinus tumors; or
  - Microvascular decompression of cranial nerves; or
  - Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum; or
  - Oval or round window graft; or
- Endolymphatic shunt for Meniere's disease; or
- Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks; or
- Movement disorders, surgery for intractable movement disorders; or
- Peripheral nerves, neuromas of the brachial plexus, when there is risk to major sensory or motor nerves; or
- Responsive neurostimulation for epilepsy; or
- Spinal cord, arteriovenous malformation surgery; or
- Spinal cord, correction of scoliosis or deformity of the spinal cord involving traction of the cord; or
- Spinal cord, decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk; or
- Spinal cord, protection where work is performed in proximity to cord and nerve roots as in the placement of new instrumentation or removal of old hardware or where there have been numerous interventions; or
- Spinal cord surgery as a result of traumatic injury; or
- Spinal cord tumors and spinal fractures (with the risk of cord compression); or
- Spinal instrumentation requiring pedicle screws, disc arthroplasty or distraction; or
- Vestibular section for vertigo.

IONM not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

0464T

92650

92651

92652

92653

95829

95860

95861

95863

95864

95867

95886

95907

95908

95910

95911

95912

95913

95925

95926

95927

95928

95929

95937

95938

95939

95940

95955

G0453

IONM performed for more than one procedure at a time is considered not medically necessary.

Procedure Code

95941

IONM of the recurrent laryngeal nerve may be considered me dically necessary in individuals undergoing:

Anterior cervical spine surgery associated with any of the following increased risk situations:
- Multilevel anterior cervical discectomy and fusion; or
- Preexisting recurrent laryngeal nerve pathology, when there is residual function, revision surgery through a scarred surgical field, reoperation or revision for failed fusion.
- Prior anterior cervical surgery, particularly revision anterior cervical discectomy and fusion, revision surgery through a scarred surgical field, reoperation for pseudarthrosis, or revision for failed fusion.
High-risk thyroid or parathyroid surgery, including:
- Repeat thyroid or parathyroid surgery; or
- Retrosternal or giant goiter; or
- Surgery for cancer; or
- Thyrotoxicosis; or
- Thyroiditis; or
- Total thyroidectomy.

IONM of the recurrent laryngeal nerve not meeting the criteria as indicated in this policy is considered experimental and investigational and therefore, non-covered because the safety and /or effectiveness of this service cannot be established by the available peer-reviewed literature.

Procedure code

95865

IONM of visual-evoked potentials is considered experimental/investigational and therefore, non-covered because the safety and /or effectiveness of this service cannot be established by the available peer-reviewed literature.

Procedure code

95930

Diagnosis Codes

Covered diagnosis codes for procedure codes: 95829, 95860, 95861, 95863, 95864, 95907, 95908, 95910, 95911, 95912, 95913, 95926, 95927, 95928, 95929, 95940, 95955, and G0453

C07

C41.2

C41.4

C47.9

C49.3

C70.0

C70.1

C70.9

C71.0

C71.1

C71.2

C71.3

C71.4

C71.5

C71.6

C71.7

C71.8

C71.9

C72.0

C72.1

C72.20

C72.21

C72.22

C72.30

C72.31

C72.32

C72.40

C72.41

C72.42

C72.50

C72.59

C72.9

C73

C75.0

C79.31

C79.32

C79.40

C79.49

C79.51

C79.89

D21.0

D32.0

D32.1

D32.9

D33.0

D33.1

D33.2

D33.3

D33.4

D33.7

D33.9

D34.5

D35.1

D36.11

D36.12

D36.13

D42.0

D42.1

D42.9

D43.0

D43.1

D43.2

D43.3

D43.4

D43.8

D43.9

D44.0

D44.2

D44.3

D44.4

D44.5

D44.6

D44.7

D49.6

E04.0

E04.1

E04.2

E04.8

E40.9

E05.00

E05.01

E05.10

E05.11

E05.20

E05.21

E05.30

E05.31

E05.40

E05.41

E05.80

E05.81

E05.90

E05.91

E07.9

E21.0

E21.1

E21.2

E21.3

E21.4

E21.5

G06.1

G10

G24.01

G24.02

G24.09

G24.1

G24.2

G24.3

G24.4

G24.5

G24.8

G24.9

G25.0

G25.1

G25.2

G25.5

G25.70

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G25.79

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G25.9

G26

G40.111

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G45.2

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G46.0

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G46.2

G46.3

G46.4

G50.0

G50.1

G52.9

G53

G54.0

G54.1

G54.2

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G54.4

G80.4

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H71.00

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H71.20

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H71.30

H71.31

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H71.33

H71.90

H71.91

H71.92

H71.93

H74.40

H74.41

H74.42

H74.43

H81.01

H81.02

H81.03

H81.4

H81.09

H83.11

H83.12

H83.13

I46.8

I46.9

I60.00

I60.01

I60.02

I60.10

I60.11

I60.12

I60.2

I60.30

I60.31

I60.32

I60.4

I60.50

I60.51

I60.52

I60.6

I60.7

I60.8

I60.9

I61.0

I61.1

I61.2

I61.3

I61.4

I61.5

I61.6

I61.8

I61.9

I62.00

I62.01

I62.02

I62.03

I62.1

I62.9

I63.00

I63.011

I63.012

I63.013

I63.019

I63.02

I63.031

I63.032

I63.033

I63.039

I63.09

I63.10

I63.111

I63.112

I63.113

I63.119

I63.12

I63.131

I63.132

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I63.139

I63.19

I63.20

I63.211

I63.212

I63.213

I63.219

I63.22

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I63.232

I63.233

I63.239

I63.29

I63.30

I63.311

I63.312

I63.313

I63.319

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

I63.333

I63.339

I63.341

I63.342

I63.343

I63.349

I63.39

I63.40

I63.411

I63.412

I63.413

I63.419

I63.421

I63.422

I63.423

I63.429

I63.431

I63.432

I63.433

I63.439

I63.441

I63.442

I63.443

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I63.49

I63.50

I63.511

I63.512

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I63.519

I63.521

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I63.523

I63.529

I63.531

I63.532

I63.533

I63.539

I63.541

I63.542

I63.543

I63.549

I63.59

I63.6

I63.81

I63.89

I63.8

I63.9

I65.01

I65.02

I65.03

I65.09

I65.1

I65.21

I65.22

I65.23

I65.29

I65.8

I65.9

I66.01

I66.02

I66.03

I66.09

I66.11

I66.12

I66.13

I66.19

I66.21

I66.22

I66.23

I66.29

I66.3

I66.8

I66.9

I67.0

I67.1

I67.2

I67.5

I67.841

I67.848

I71.00

I71.01

I71.02

I71.03

I71.1

I71.2

I71.3

I71.4

I71.5

I71.6

I71.8

I71.9

I77.71

I77.74

I77.75

I77.79

I79.0

M21.751

M21.752

M21.759

M21.761

M21.762

M21.763

M21.764

M21.769

M40.00

M40.03

M40.04

M40.05

M40.10

M40.12

M40.13

M40.14

M40.15

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M40.30

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

M41.112

M41.113

M41.114

M41.115

M41.116

M41.117

M41.119

M41.122

M41.123

M41.124

M41.125

M41.126

M41.127

M41.129

M41.20

M41.22

M41.23

M41.24

M41.25

M41.26

M41.27

M41.30

M41.34

M41.35

M41.40

M41.41

M41.42

M41.43

M41.44

M41.45

M41.46

M41.47

M41.50

M41.52

M41.53

M41.54

M41.55

M41.56

M41.57

M41.80

M41.82

M41.83

M41.84

M41.85

M41.86

M41.87

M41.9

M43.01

M43.02

M43.03

M43.04

M43.05

M43.06

M43.07

M43.08

M43.09

M43.11

M43.12

M43.13

M43.14

M43.15

M43.16

M43.17

M43.18

M43.19

M43.8X1

M43.8X2

M43.8X3

M43.8X4

M43.8X5

M43.8X6

M43.8X7

M43.8X8

M43.8X9

M43.9

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.10

M47.11

M47.12

M47.13

M47.14

M47.15

M47.16

M47.21

M47.22

M47.23

M47.24

M47.25

M47.26

M47.27

M47.28

M47.811

M47.812

M47.813

M47.816

M47.817

M47.818

M47.891

M47.892

M47.893

M47.896

M47.897

M47.898

M48.00

M48.01

M48.02

M48.03

M48.04

M48.05

M48.061

M48.062

M48.07

M48.08

M50.00

M50.01

M50.020

M50.021

M50.022

M50.023

M50.03

M50.10

M50.11

M50.120

M50.121

M50.122

M50.123

M50.13

M50.20

M50.21

M50.220

M50.221

M50.222

M50.223

M50.23

M50.30

M50.31

M50.321

M50.322

M50.323

M50.33

M50.80

M50.81

M50.821

M50.822

M50.823

M50.83

M50.90

M50.91

M50.920

M50.921

M50.922

M50.923

M50.93

M51.04

M51.05

M51.06

M51.14

M51.15

M51.16

M51.17

M51.24

M51.25

M51.26

M51.27

M51.34

M51.35

M51.36

M51.37

M51.84

M51.85

M51.86

M51.87

M51.9

M53.0

M53.1

M54.11

M54.12

M54.13

M54.14

M54.15

M54.16

M54.17

M54.18

M54.2

M54.30

M54.31

M54.32

M96.1

M96.2

M96.3

M96.4

M96.5

M99.20

M99.21

M99.22

M99.23

M99.24

M99.25

M99.26

M99.27

M99.28

M99.29

M99.30

M99.31

M99.32

M99.33

M99.34

M99.35

M99.36

M99.37

M99.38

M99.39

M99.40

M99.41

M99.42

M99.43

M99.44

M99.45

M99.46

M99.47

M99.48

M99.49

M99.50

M99.51

M99.52

M99.53

M99.54

M99.55

M99.56

M99.57

M99.58

M99.59

M99.60

M99.61

M99.62

M99.63

M99.64

M99.65

M99.66

M99.67

M99.68

M99.69

M99.70

M99.71

M99.72

M99.73

M99.74

M99.75

M99.76

M99.77

M99.78

M99.79

P11.1

P11.2

P11.3

P11.4

P11.5

P11.9

P14.0

P14.1

P14.2

P14.3

P14.8

P14.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.8

Q07.00

Q07.01

Q07.02

Q07.03

Q25.72

Q27.39

Q27.9

Q28.2

Q28.3

Q77.8

Q77.9

Q85.00

Q85.01

Q85.02

Q85.03

Q85.09

S06.1X0A

S06.1X0D

S06.1X0S

S06.1X1A

S06.1X1D

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S06.1X2A

S06.1X2D

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S06.4X0A

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S06.4X1A

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S06.4X2A

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S06.4X3A

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S06.4X4A

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S06.4X5A

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S06.4X6A

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S06.4X7A

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S06.4X9A

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S06.5X0A

S06.5X0D

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S06.5X1A

S06.5X1D

S06.5X1S

S06.5X2A

S06.5X2D

S06.5X2S

S06.5X3A

S06.5X3D

S06.5X3S

S06.5X4A

S06.5X4D

S06.5X4S

S06.5X5A

S06.5X5D

S06.5X5S

S06.5X6A

S06.5X6D

S06.5X6S

S06.5X7A

S06.5X8A

S06.5X9A

S06.5X9D

S06.5X9S

S06.6X0A

S06.6X0D

S06.6X0S

S06.6X1A

S06.6X1D

S06.6X1S

S06.6X2A

S06.6X2D

S06.6X2S

S06.6X3A

S06.6X3D

S06.6X3S

S06.6X4A

S06.6X4D

S06.6X4S

S06.6X5A

S06.6X5D

S06.6X5S

S06.6X6A

S06.6X6D

S06.6X6S

S06.6X7A

S06.6X8A

S06.6X9A

S06.6X9D

S06.6X9S

S06.890A

S06.890D

S06.890S

S06.891A

S06.891D

S06.891S

S06.892A

S06.892D

S06.892S

S06.893A

S06.893D

S06.893S

S06.894A

S06.894D

S06.894S

S06.895A

S06.895D

S06.895S

S06.896A

S06.896D

S06.896S

S06.897A

S06.898A

S06.899A

S06.899D

S06.899S

S06.9X0A

S06.9X0D

S06.9X0S

S06.9X1A

S06.9X1D

S06.9X1S

S06.9X2A

S06.9X2D

S06.9X2S

S06.9X3A

S06.9X3D

S06.9X3S

S06.9X4A

S06.9X4D

S06.9X4S

S06.9X5A

S06.9X5D

S06.9X5S

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X7A

S06.9X8A

S06.9X9A

S06.9X9D

S06.9X9S

S12.000A

S12.000B

S12.000S

S12.001A

S12.001B

S12.001S

S12.01XS

S12.02XS

S12.030S

S12.031S

S12.040S

S12.041S

S12.090S

S12.091S

S12.100A

S12.100B

S12.100S

S12.101A

S12.101B

S12.101S

S12.110A

S12.110B

S12.110S

S12.111A

S12.111B

S12.111S

S12.112A

S12.112B

S12.112S

S12.120A

S12.120B

S12.120S

S12.130A

S12.130B

S12.130S

S12.131A

S12.131B

S12.131S

S12.14XA

S12.14XB

S12.14XS

S12.150A

S12.150B

S12.150S

S12.151A

S12.151B

S12.151S

S12.190A

S12.190B

S12.190S

S12.191A

S12.191B

S12.191S

S12.200A

S12.200B

S12.200S

S12.201A

S12.201B

S12.201S

S12.230A

S12.230B

S12.230S

S12.231A

S12.231B

S12.231S

S12.24XA

S12.24XB

S12.24XS

S12.250A

S12.250B

S12.250S

S12.251A

S12.251B

S12.251S

S12.290A

S12.290B

S12.290S

S12.291A

S12.291B

S12.291S

S12.300A

S12.300B

S12.300S

S12.301A

S12.301B

S12.301S

S12.330A

S12.330B

S12.330S

S12.331A

S12.331B

S12.331S

S12.34XA

S12.34XB

S12.34XS

S12.350A

S12.350B

S12.350S

S12.351A

S12.351B

S12.351S

S12.390A

S12.390B

S12.390S

S12.391A

S12.391B

S12.391S

S12.400A

S12.400B

S12.400S

S12.401A

S12.401B

S12.401S

S12.430A

S12.430B

S12.430S

S12.431A

S12.431B

S12.431S

S12.44XA

S12.44XB

S12.44XS

S12.450A

S12.450B

S12.450S

S12.451A

S12.451B

S12.451S

S12.490A

S12.490B

S12.490S

S12.491A

S12.491B

S12.491S

S12.500A

S12.500B

S12.500S

S12.501A

S12.501B

S12.501S

S12.530A

S12.530B

S12.530S

S12.531A

S12.531B

S12.531S

S12.54XA

S12.54XB

S12.54XS

S12.550A

S12.550B

S12.550S

S12.551A

S12.551B

S12.551S

S12.590A

S12.590B

S12.590S

S12.591A

S12.591B

S12.591S

S12.600A

S12.600B

S12.600S

S12.601A

S12.601B

S12.601S

S12.630A

S12.630B

S12.630S

S12.631A

S12.631B

S12.631S

S12.64XA

S12.64XB

S12.64XS

S12.650A

S12.650B

S12.650S

S12.651A

S12.651B

S12.651S

S12.690A

S12.690B

S12.690S

S12.691A

S12.691B

S12.691S

S12.9XXA

S12.9XXD

S12.9XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118D

S14.118S

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128D

S14.128S

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151S

S14.152A

S14.152S

S14.153A

S14.153S

S14.154A

S14.154S

S14.155A

S14.155S

S14.156A

S14.156S

S14.157A

S14.157S

S14.158A

S14.158S

S14.159A

S14.159S

S14.2XXA

S14.2XXS

S14.3XXA

S14.3XXS

S14.4XXA

S14.4XXS

S14.5XXA

S14.5XXS

S22.000A

S22.000B

S22.000S

S22.001A

S22.001B

S22.001S

S22.002A

S22.002B

S22.002S

S22.008A

S22.008B

S22.008S

S22.009A

S22.009B

S22.009S

S22.010A

S22.010B

S22.010S

S22.011A

S22.011B

S22.011S

S22.012A

S22.012B

S22.012S

S22.018A

S22.018B

S22.018S

S22.019A

S22.019B

S22.019S

S22.020A

S22.020B

S22.020S

S22.021A

S22.021B

S22.021S

S22.022A

S22.022B

S22.022S

S22.028A

S22.028B

S22.028S

S22.029A

S22.029B

S22.029S

S22.030A

S22.030B

S22.030S

S22.031A

S22.031B

S22.031S

S22.032A

S22.032B

S22.032S

S22.038A

S22.038B

S22.038S

S22.039A

S22.039B

S22.039S

S22.040A

S22.040B

S22.040S

S22.041A

S22.041B

S22.041S

S22.042A

S22.042B

S22.042S

S22.048A

S22.048B

S22.048S

S22.049A

S22.049B

S22.049S

S22.050A

S22.050B

S22.050S

S22.051A

S22.051B

S22.051S

S22.052A

S22.052B

S22.052S

S22.058A

S22.058B

S22.058S

S22.059A

S22.059B

S22.059S

S22.060A

S22.060B

S22.060S

S22.061A

S22.061B

S22.061S

S22.062A

S22.062B

S22.062S

S22.068A

S22.068B

S22.068S

S22.069A

S22.069B

S22.069S

S22.070A

S22.070B

S22.070S

S22.071A

S22.071B

S22.071S

S22.072A

S22.072B

S22.072S

S22.078A

S22.078B

S22.078S

S22.079A

S22.079B

S22.079S

S22.080A

S22.080B

S22.080S

S22.081A

S22.081B

S22.081S

S22.082A

S22.082B

S22.082S

S22.088A

S22.088B

S22.088S

S22.089A

S22.089B

S22.089S

S24.0XXA

S24.0XXS

S24.101A

S24.101S

S24.102A

S24.102S

S24.103A

S24.103S

S24.104A

S24.104S

S24.109A

S24.109S

S24.111A

S24.111S

S24.112A

S24.112S

S24.113A

S24.113S

S24.114A

S24.114S

S24.119A

S24.119S

S24.131A

S24.131S

S24.132A

S24.132S

S24.133A

S24.133S

S24.134A

S24.134S

S24.139A

S24.139S

S24.141A

S24.141S

S24.142A

S24.142S

S24.143A

S24.143S

S24.144A

S24.144S

S24.149A

S24.149S

S24.151A

S24.151S

S24.152A

S24.152S

S24.153A

S24.153S

S24.154A

S24.154S

S24.159A

S24.159S

S24.2XXA

S24.2XXS

S32.000A

S32.000B

S32.000S

S32.001A

S32.001B

S32.001S

S32.002A

S32.002B

S32.002S

S32.008A

S32.008B

S32.008S

S32.009A

S32.009B

S32.009S

S32.010A

S32.010B

S32.010S

S32.011A

S32.011B

S32.011S

S32.012A

S32.012B

S32.012S

S32.018A

S32.018B

S32.018S

S32.019A

S32.019B

S32.019S

S32.020A

S32.020B

S32.020S

S32.021A

S32.021B

S32.021S

S32.022A

S32.022B

S32.022S

S32.028A

S32.028B

S32.028S

S32.029A

S32.029B

S32.029S

S32.030A

S32.030B

S32.030S

S32.031A

S32.031B

S32.031S

S32.032A

S32.032B

S32.032S

S32.038A

S32.038B

S32.038S

S32.039A

S32.039B

S32.039S

S32.040A

S32.040B

S32.040S

S32.041A

S32.041B

S32.041S

S32.042A

S32.042B

S32.042S

S32.048A

S32.048B

S32.048S

S32.049A

S32.049B

S32.049S

S32.050A

S32.050B

S32.050S

S32.051A

S32.051B

S32.051S

S32.052A

S32.052B

S32.052S

S32.058A

S32.058B

S32.058S

S32.059A

S32.059B

S32.059S

S32.10XA

S32.10XB

S32.10XS

S32.110A

S32.110B

S32.110S

S32.111A

S32.111B

S32.111S

S32.112A

S32.112B

S32.112S

S32.119A

S32.119B

S32.119S

S32.120A

S32.120B

S32.120S

S32.121A

S32.121B

S32.121S

S32.122A

S32.122B

S32.122S

S32.129A

S32.129B

S32.129S

S32.130A

S32.130B

S32.130S

S32.131A

S32.131B

S32.131S

S32.132A

S32.132B

S32.132S

S32.139A

S32.139B

S32.139S

S32.14XA

S32.14XB

S32.14XS

S32.15XA

S32.15XB

S32.15XS

S32.16XA

S32.16XB

S32.16XS

S32.17XA

S32.17XB

S32.17XS

S32.19XA

S32.19XB

S32.19XS

S32.2XXA

S32.2XXB

S32.2XXS

S34.01XA

S34.01XS

S34.02XA

S34.02XS

S34.101A

S34.101S

S34.102A

S34.102S

S34.103A

S34.103S

S34.104A

S34.104S

S34.105A

S34.105S

S34.109A

S34.109S

S34.111A

S34.111S

S34.112A

S34.112S

S34.113A

S34.113S

S34.114A

S34.114S

S34.115A

S34.115S

S34.119A

S34.119S

S34.121A

S34.121S

S34.122A

S34.122S

S34.123A

S34.123S

S34.124A

S34.124S

S34.125A

S34.125S

S34.129A

S34.129S

S34.131A

S34.131S

S34.132A

S34.132S

S34.139A

S34.139S

S34.21XA

S34.21XS

S34.22XA

S34.22XS

S34.3XXA

S34.3XXS

S34.4XXA

S34.4XXS

S44.00XA

S44.00XS

S44.01XA

S44.01XS

S44.02XA

S44.02XS

S44.10XA

S44.10XS

S44.11XA

S44.11XS

S44.12XA

S44.12XS

S44.20XA

S44.20XS

S44.21XA

S44.21XS

S44.22XA

S44.22XS

S44.30XA

S44.30XS

S44.31XA

S44.31XS

S44.32XA

S44.32XS

S44.40XA

S44.40XS

S44.41XA

S44.41XS

S44.42XA

S44.42XS

S44.50XA

S44.50XS

S44.51XA

S44.51XS

S44.52XA

S44.52XS

S44.8X1A

S44.8X1S

S44.8X2A

S44.8X2S

S44.8X9A

S44.8X9S

S44.90XA

S44.90XS

S44.91XA

S44.91XS

S44.92XA

S44.92XS

S54.00XA

S54.00XS

S54.01XA

S54.01XS

S54.02XA

S54.02XS

S54.10XA

S54.10XS

S54.11XA

S54.11XS

S54.12XA

S54.12XS

S54.20XA

S54.20XS

S54.21XA

S54.21XS

S54.22XA

S54.22XS

S54.30XA

S54.30XS

S54.31XA

S54.31XS

S54.32XA

S54.32XS

S54.8X1A

S54.8X1S

S54.8X2A

S54.8X2S

S54.8X9A

S54.8X9S

S54.90XA

S54.91XA

S54.92XA

S64.00XA

S64.00XS

S64.01XA

S64.01XS

S64.02XA

S64.02XS

S64.10XA

S64.10XS

S64.11XA

S64.11XS

S64.12XA

S64.12XS

S64.20XA

S64.20XS

S64.21XA

S64.21XS

S64.22XA

S64.22XS

S64.30XA

S64.30XS

S64.31XA

S64.31XS

S64.32XA

S64.32XS

S64.40XA

S64.40XS

S64.490A

S64.490S

S64.491A

S64.491S

S64.492A

S64.492S

S64.493A

S64.493S

S64.494A

S64.494S

S64.495A

S64.495S

S64.496A

S64.496S

S64.497A

S64.497S

S64.498A

S64.498S

S64.8X1A

S64.8X1S

S64.8X2A

S64.8X2S

S64.8X9A

S64.8X9S

S64.90XA

S64.90XS

S64.91XA

S64.91XS

S64.92XA

S64.92XS

S74.00XA

S74.00XS

S74.01XA

S74.01XS

S74.02XA

S74.02XS

S74.10XA

S74.10XS

S74.11XA

S74.11XS

S74.12XA

S74.12XS

S74.20XA

S74.20XS

S74.21XA

S74.21XS

S74.22XA

S74.22XS

S74.8X1A

S74.8X1S

S74.8X2A

S74.8X2S

S74.8X9A

S74.8X9S

S74.90XA

S74.90XS

S74.91XA

S74.91XS

S74.92XA

S74.92XS

S84.00XA

S84.00XS

S84.01XA

S84.01XS

S84.02XA

S84.02XS

S84.10XA

S84.10XS

S84.11XA

S84.11XS

S84.12XA

S84.12XS

S84.20XA

S84.20XS

S84.21XA

S84.21XS

S84.22XA

S84.22XS

S84.801A

S84.801S

S84.802A

S84.802S

S84.809A

S84.809S

S84.90XA

S84.90XS

S84.91XA

S84.91XS

S84.92XA

S84.92XS

S94.00XA

S94.00XS

S94.01XA

S94.01XS

S94.02XA

S94.02XS

S94.10XA

S94.10XS

S94.11XA

S94.11XS

S94.12XA

S94.12XS

S94.20XA

S94.20XS

S94.21XA

S94.21XS

S94.22XA

S94.22XS

S94.30XA

S94.30XS

S94.31XA

S94.31XS

S94.32XA

S94.32XS

S94.8X1A

S94.8X1S

S94.8X2A

S94.8X2S

S94.8X9A

S94.8X9S

S94.90XA

S94.90XS

S94.91XA

S94.91XS

S94.92XA

S94.92XS

T68.XXXA

T68.XXXD

T68.XXXS

T84.216A

T84.216D

T84.216S

T84.226A

T84.226D

T84.226S

T84.296A

T84.296D

T84.296S

T84.310A

T84.310D

T84.310S

T84.318A

T84.318D

T84.318S

T84.320A

T84.320D

T84.320S

T84.328A

T84.328D

T84.328S

T84.390A

T84.390D

T84.390S

T84.398A

T84.398D

T84.398S

Z45.41

Z45.42

Z45.49

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-20 Revised policy

Updated language

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed Procedure codes 92585; and 92586; and
Added Procedure codes 92650; 92651; 92652; and 92653

Internal Medical Policy Committee 9-21-2021 Coding update;

Added Diagnosis codes H81.41; H81.42; H81.43; H81.49; and H83.19

Internal Medical Policy Committee 9-28-2022 Revision of Policy

Removed Procedure code 95941 and 95942
Updated language throughout policy

Internal Medical Policy Committee 5-23-2023 - Effective July 03, 2023

Added criteria
Added procedure code 95941

Internal Medical Policy Committee 11-15-2023 - Effective October 01, 2023

Added Diagnosis codes G93.42, G93.43 and G93.44
Removed Diagnosis codes G20.
Added Diagnosis codes C75.0, D345, D35.1, D44.0, D44.2, E04.0, E04.1, E04.2, E04.8, E04.9, E21.0, E21.1, E21.2, E21.3, E21.4, E21.5, and H81.4
Removed Diagnosis codes H81.41, H81.42, H81.43, H81.49, H83.19, I63.8, S06.2X7D and S06.2X7S

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: M-13-045

Section: Diagnostic Medical

Effective Date: September 01, 2019

Revised Date: September 22, 2022

Revision Effective Date: November 07, 2022

Last Reviewed: September 28, 2022

Archived Date: July 02, 2023

Applies To: Commercial and Medicaid Expansion

Description

CriteriaI

ONM, includes somatosensory-evoked potentials, motor-evoked potentials using transcranial electrical stimulation, brainstem auditory-evoked potentials, electromyography (EMG) of cranial nerves, electroencephalogram (EEG), and electrocorticography (ECoG), may be considered medically necessary

When performed by an operator who is certified by theAmerican Board of Medical Specialties (ABMS); and
Monitoring only one (1) procedure at a time; and
For ANY of the following procedures:
- Aortic arch, its branch vessels, or thoracic aorta surgery, including carotid artery surgery, when there is risk of cerebral or spinal cord ischemia; or
- Aortic procedures, distal, where there is risk of ischemia to spinal cord; or
- Arteriovenous malformations (AVMs), surgery or embolization for intracranial AVMs; or
- Basal ganglia movement disorders; or
- Brain, deep stimulation; or
- Brain, resection of epileptogenic tissue or tumor; or
- Brain, resection of tissue close to the eloquent brain cortex and requiring brain mapping; or
- Brain surgery as a result of traumatic injury; or
- Bronchial artery arteriovenous malformations or tumors, embolization of; or
- Carotid artery arteriography, during which there is a test occlusion of the carotid artery; or
- Cerebral vascular aneurysms; or
- Circulatory arrest with hypothermia [does not include surgeries performed under circulatory bypass (e.g., coronary artery bypass grafting (CABG), ventricular aneurysms); or
- Cranial nerve protection during:
  - Resection of tumors involving the cranial nerves; or
  - Cavernous sinus tumors; or
  - Microvascular decompression of cranial nerves; or
  - Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum; or
  - Oval or round window graft; or
- Endolymphatic shunt for Meniere's disease; or
- Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks; or
- Movement disorders, surgery for intractable movement disorders; or
- Peripheral nerves, neuromas of the brachial plexus, when there is risk to major sensory or motor nerves; or
- Responsive neurostimulation for epilepsy; or
- Spinal cord, arteriovenous malformation surgery; or
- Spinal cord, correction of scoliosis or deformity of the spinal cord involving traction of the cord; or
- Spinal cord, decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk; or
- Spinal cord, protection where work is performed in proximity to cord and nerve roots as in the placement of new instrumentation or removal of old hardware or where there have been numerous interventions; or
- Spinal cord surgery as a result of traumatic injury; or
- Spinal cord tumors and spinal fractures (with the risk of cord compression); or
- Spinal instrumentation requiring pedicle screws, disc arthroplasty or distraction; or
- Vestibular section for vertigo.

IONM not meeting the criteria as indicated in this policy is considered not medically necessary.

Procedure Codes

0464T

92650

92651

92652

92653

95829

95860

95861

95863

95864

95867

95886

95907

95908

95910

95911

95912

95913

95925

95926

95927

95928

95929

95937

95938

95939

95940

95955

G0453

IONM of the recurrent laryngeal nerve may be considered medically necessary in individuals undergoing:

Anterior cervical spine surgery associated with any of the following increased risk situations:
- Multilevel anterior cervical discectomy and fusion; or
- Preexisting recurrent laryngeal nerve pathology, when there is residual function, revision surgery through a scarred surgical field, reoperation or revision for failed fusion.
- Prior anterior cervical surgery, particularly revision anterior cervical discectomy and fusion, revision surgery through a scarred surgical field, reoperation for pseudarthrosis, or revision for failed fusion.
High-risk thyroid or parathyroid surgery, including:
- Repeat thyroid or parathyroid surgery; or
- Retrosternal or giant goiter; or
- Surgery for cancer; or
- Thyrotoxicosis; or
- Thyroiditis; or
- Total thyroidectomy.

Procedure Codes

95865

Procedure code

95930

Diagnosis Codes

Covered diagnosis codes for procedure codes: 95829, 95860, 95861, 95863, 95864, 95907, 95908, 95910, 95911, 95912, 95913, 95926, 95927, 95928, 95929, 95940, 95955, and G0453

C07

C41.2

C41.4

C47.9

C49.3

C70.0

C70.1

C70.9

C71.0

C71.1

C71.2

C71.3

C71.4

C71.5

C71.6

C71.7

C71.8

C71.9

C72.0

C72.1

C72.20

C72.21

C72.22

C72.30

C72.31

C72.32

C72.40

C72.41

C72.42

C72.50

C72.59

C72.9

C73

C79.31

C79.32

C79.40

C79.49

C79.51

C79.89

D21.0

D32.0

D32.1

D32.9

D33.0

D33.1

D33.2

D33.3

D33.4

D33.7

D33.9

D36.11

D36.12

D36.13

D42.0

D42.1

D42.9

D43.0

D43.1

D43.2

D43.3

D43.4

D43.8

D43.9

D44.3

D44.4

D44.5

D44.6

D44.7

D49.6

E05.00

E05.01

E05.10

E05.11

E05.20

E05.21

E05.30

E05.31

E05.40

E05.41

E05.80

E05.81

E05.90

E05.91

E07.9

G06.1

G10

G20

G24.01

G24.02

G24.09

G24.1

G24.2

G24.3

G24.4

G24.5

G24.8

G24.9

G25.0

G25.1

G25.2

G25.5

G25.70

G25.71

G25.79

G25.89

G25.9

G26

G40.111

G40.119

G40.211

G40.219

G40.311

G40.319

G40.411

G40.419

G40.803

G40.804

G45.0

G45.1

G45.2

G45.8

G45.9

G46.0

G46.1

G46.2

G46.3

G46.4

G50.0

G50.1

G52.9

G53

G54.0

G54.1

G54.2

G54.3

G54.4

G80.4

G80.8

G80.9

G83.4

G93.5

G95.0

G95.19

G95.20

G95.29

G95.89

G95.9

H71.00

H71.01

H71.02

H71.03

H71.10

H71.11

H71.12

H71.13

H71.20

H71.21

H71.22

H71.23

H71.30

H71.31

H71.32

H71.33

H71.90

H71.91

H71.92

H71.93

H74.40

H74.41

H74.42

H74.43

H81.01

H81.02

H81.03

H81.09

H81.41

H81.42

H81.43

H81.49

H83.11

H83.12

H83.13

H83.19

I46.8

I46.9

I60.00

I60.01

I60.02

I60.10

I60.11

I60.12

I60.2

I60.30

I60.31

I60.32

I60.4

I60.50

I60.51

I60.52

I60.6

I60.7

I60.8

I60.9

I61.0

I61.1

I61.2

I61.3

I61.4

I61.5

I61.6

I61.8

I61.9

I62.00

I62.01

I62.02

I62.03

I62.1

I62.9

I63.00

I63.011

I63.012

I63.013

I63.019

I63.02

I63.031

I63.032

I63.033

I63.039

I63.09

I63.10

I63.111

I63.112

I63.113

I63.119

I63.12

I63.131

I63.132

I63.133

I63.139

I63.19

I63.20

I63.211

I63.212

I63.213

I63.219

I63.22

I63.231

I63.232

I63.233

I63.239

I63.29

I63.30

I63.311

I63.312

I63.313

I63.319

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

I63.333

I63.339

I63.341

I63.342

I63.343

I63.349

I63.39

I63.40

I63.411

I63.412

I63.413

I63.419

I63.421

I63.422

I63.423

I63.429

I63.431

I63.432

I63.433

I63.439

I63.441

I63.442

I63.443

I63.449

I63.49

I63.50

I63.511

I63.512

I63.513

I63.519

I63.521

I63.522

I63.523

I63.529

I63.531

I63.532

I63.533

I63.539

I63.541

I63.542

I63.543

I63.549

I63.59

I63.6

I63.81

I63.89

I63.8

I63.9

I65.01

I65.02

I65.03

I65.09

I65.1

I65.21

I65.22

I65.23

I65.29

I65.8

I65.9

I66.01

I66.02

I66.03

I66.09

I66.11

I66.12

I66.13

I66.19

I66.21

I66.22

I66.23

I66.29

I66.3

I66.8

I66.9

I67.0

I67.1

I67.2

I67.5

I67.841

I67.848

I71.00

I71.01

I71.02

I71.03

I71.1

I71.2

I71.3

I71.4

I71.5

I71.6

I71.8

I71.9

I77.71

I77.74

I77.75

I77.79

I79.0

M21.751

M21.752

M21.759

M21.761

M21.762

M21.763

M21.764

M21.769

M40.00

M40.03

M40.04

M40.05

M40.10

M40.12

M40.13

M40.14

M40.15

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M40.30

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

M41.112

M41.113

M41.114

M41.115

M41.116

M41.117

M41.119

M41.122

M41.123

M41.124

M41.125

M41.126

M41.127

M41.129

M41.20

M41.22

M41.23

M41.24

M41.25

M41.26

M41.27

M41.30

M41.34

M41.35

M41.40

M41.41

M41.42

M41.43

M41.44

M41.45

M41.46

M41.47

M41.50

M41.52

M41.53

M41.54

M41.55

M41.56

M41.57

M41.80

M41.82

M41.83

M41.84

M41.85

M41.86

M41.87

M41.9

M43.01

M43.02

M43.03

M43.04

M43.05

M43.06

M43.07

M43.08

M43.09

M43.11

M43.12

M43.13

M43.14

M43.15

M43.16

M43.17

M43.18

M43.19

M43.8X1

M43.8X2

M43.8X3

M43.8X4

M43.8X5

M43.8X6

M43.8X7

M43.8X8

M43.8X9

M43.9

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.10

M47.11

M47.12

M47.13

M47.14

M47.15

M47.16

M47.21

M47.22

M47.23

M47.24

M47.25

M47.26

M47.27

M47.28

M47.811

M47.812

M47.813

M47.816

M47.817

M47.818

M47.891

M47.892

M47.893

M47.896

M47.897

M47.898

M48.00

M48.01

M48.02

M48.03

M48.04

M48.05

M48.061

M48.062

M48.07

M48.08

M50.00

M50.01

M50.020

M50.021

M50.022

M50.023

M50.03

M50.10

M50.11

M50.120

M50.121

M50.122

M50.123

M50.13

M50.20

M50.21

M50.220

M50.221

M50.222

M50.223

M50.23

M50.30

M50.31

M50.321

M50.322

M50.323

M50.33

M50.80

M50.81

M50.821

M50.822

M50.823

M50.83

M50.90

M50.91

M50.920

M50.921

M50.922

M50.923

M50.93

M51.04

M51.05

M51.06

M51.14

M51.15

M51.16

M51.17

M51.24

M51.25

M51.26

M51.27

M51.34

M51.35

M51.36

M51.37

M51.84

M51.85

M51.86

M51.87

M51.9

M53.0

M53.1

M54.11

M54.12

M54.13

M54.14

M54.15

M54.16

M54.17

M54.18

M54.2

M54.30

M54.31

M54.32

M96.1

M96.2

M96.3

M96.4

M96.5

M99.20

M99.21

M99.22

M99.23

M99.24

M99.25

M99.26

M99.27

M99.28

M99.29

M99.30

M99.31

M99.32

M99.33

M99.34

M99.35

M99.36

M99.37

M99.38

M99.39

M99.40

M99.41

M99.42

M99.43

M99.44

M99.45

M99.46

M99.47

M99.48

M99.49

M99.50

M99.51

M99.52

M99.53

M99.54

M99.55

M99.56

M99.57

M99.58

M99.59

M99.60

M99.61

M99.62

M99.63

M99.64

M99.65

M99.66

M99.67

M99.68

M99.69

M99.70

M99.71

M99.72

M99.73

M99.74

M99.75

M99.76

M99.77

M99.78

M99.79

P11.1

P11.2

P11.3

P11.4

P11.5

P11.9

P14.0

P14.1

P14.2

P14.3

P14.8

P14.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.8

Q07.00

Q07.01

Q07.02

Q07.03

Q25.72

Q27.39

Q27.9

Q28.2

Q28.3

Q77.8

Q77.9

Q85.00

Q85.01

Q85.02

Q85.03

Q85.09

S06.1X0A

S06.1X0D

S06.1X0S

S06.1X1A

S06.1X1D

S06.1X1S

S06.1X2A

S06.1X2D

S06.1X2S

S06.1X3A

S06.1X3D

S06.1X3S

S06.1X4A

S06.1X4D

S06.1X4S

S06.1X5A

S06.1X5D

S06.1X5S

S06.1X6A

S06.1X6D

S06.1X6S

S06.1X7A

S06.1X8A

S06.1X9A

S06.1X9D

S06.1X9S

S06.2X0A

S06.2X0D

S06.2X0S

S06.2X1A

S06.2X1D

S06.2X1S

S06.2X2A

S06.2X2D

S06.2X2S

S06.2X3A

S06.2X3D

S06.2X3S

S06.2X4A

S06.2X4D

S06.2X4S

S06.2X5A

S06.2X5D

S06.2X5S

S06.2X6A

S06.2X6D

S06.2X6S

S06.2X7A

S06.2X7D

S06.2X7S

S06.2X8A

S06.2X9A

S06.2X9D

S06.2X9S

S06.300A

S06.300D

S06.300S

S06.301A

S06.301D

S06.301S

S06.302A

S06.302D

S06.302S

S06.303A

S06.303D

S06.303S

S06.304A

S06.304D

S06.304S

S06.305A

S06.305D

S06.305S

S06.306A

S06.306D

S06.306S

S06.307A

S06.308A

S06.309A

S06.309D

S06.309S

S06.310A

S06.310D

S06.310S

S06.311A

S06.311D

S06.311S

S06.312A

S06.312D

S06.312S

S06.313A

S06.313D

S06.313S

S06.314A

S06.314D

S06.314S

S06.315A

S06.315D

S06.315S

S06.316A

S06.316D

S06.316S

S06.317A

S06.318A

S06.319A

S06.319D

S06.319S

S06.320A

S06.320D

S06.320S

S06.321A

S06.321D

S06.321S

S06.322A

S06.322D

S06.322S

S06.323A

S06.323D

S06.323S

S06.324A

S06.324D

S06.324S

S06.325A

S06.325D

S06.325S

S06.326A

S06.326D

S06.326S

S06.327A

S06.328A

S06.329A

S06.329D

S06.329S

S06.330A

S06.330D

S06.330S

S06.331A

S06.331D

S06.331S

S06.332A

S06.332D

S06.332S

S06.333A

S06.333D

S06.333S

S06.334A

S06.334D

S06.334S

S06.335A

S06.335D

S06.335S

S06.336A

S06.336D

S06.336S

S06.337A

S06.338A

S06.339A

S06.339D

S06.339S

S06.340A

S06.340D

S06.340S

S06.341A

S06.341D

S06.341S

S06.342A

S06.342D

S06.342S

S06.343A

S06.343D

S06.343S

S06.344A

S06.344D

S06.344S

S06.345A

S06.345D

S06.345S

S06.346A

S06.346D

S06.346S

S06.347A

S06.348A

S06.349A

S06.349D

S06.349S

S06.350A

S06.350D

S06.350S

S06.351A

S06.351D

S06.351S

S06.352A

S06.352D

S06.352S

S06.353A

S06.353D

S06.353S

S06.354A

S06.354D

S06.354S

S06.355A

S06.355D

S06.355S

S06.356A

S06.356D

S06.356S

S06.357A

S06.358A

S06.359A

S06.359D

S06.359S

S06.360A

S06.360D

S06.360S

S06.361A

S06.361D

S06.361S

S06.362A

S06.362D

S06.362S

S06.363A

S06.363D

S06.363S

S06.364A

S06.364D

S06.364S

S06.365A

S06.365D

S06.365S

S06.366A

S06.366D

S06.366S

S06.367A

S06.368A

S06.369A

S06.369D

S06.369S

S06.370A

S06.370D

S06.370S

S06.371A

S06.371D

S06.371S

S06.372A

S06.372D

S06.372S

S06.373A

S06.373D

S06.373S

S06.374A

S06.374D

S06.374S

S06.375A

S06.375D

S06.375S

S06.376A

S06.376D

S06.376S

S06.377A

S06.378A

S06.379A

S06.379D

S06.379S

S06.380A

S06.380D

S06.380S

S06.381A

S06.381D

S06.381S

S06.382A

S06.382D

S06.382S

S06.383A

S06.383D

S06.383S

S06.384A

S06.384D

S06.384S

S06.385A

S06.385D

S06.385S

S06.386A

S06.386D

S06.386S

S06.387A

S06.388A

S06.389A

S06.389D

S06.389S

S06.4X0A

S06.4X0D

S06.4X0S

S06.4X1A

S06.4X1D

S06.4X1S

S06.4X2A

S06.4X2D

S06.4X2S

S06.4X3A

S06.4X3D

S06.4X3S

S06.4X4A

S06.4X4D

S06.4X4S

S06.4X5A

S06.4X5D

S06.4X5S

S06.4X6A

S06.4X6D

S06.4X6S

S06.4X7A

S06.4X8A

S06.4X9A

S06.4X9D

S06.4X9S

S06.5X0A

S06.5X0D

S06.5X0S

S06.5X1A

S06.5X1D

S06.5X1S

S06.5X2A

S06.5X2D

S06.5X2S

S06.5X3A

S06.5X3D

S06.5X3S

S06.5X4A

S06.5X4D

S06.5X4S

S06.5X5A

S06.5X5D

S06.5X5S

S06.5X6A

S06.5X6D

S06.5X6S

S06.5X7A

S06.5X8A

S06.5X9A

S06.5X9D

S06.5X9S

S06.6X0A

S06.6X0D

S06.6X0S

S06.6X1A

S06.6X1D

S06.6X1S

S06.6X2A

S06.6X2D

S06.6X2S

S06.6X3A

S06.6X3D

S06.6X3S

S06.6X4A

S06.6X4D

S06.6X4S

S06.6X5A

S06.6X5D

S06.6X5S

S06.6X6A

S06.6X6D

S06.6X6S

S06.6X7A

S06.6X8A

S06.6X9A

S06.6X9D

S06.6X9S

S06.890A

S06.890D

S06.890S

S06.891A

S06.891D

S06.891S

S06.892A

S06.892D

S06.892S

S06.893A

S06.893D

S06.893S

S06.894A

S06.894D

S06.894S

S06.895A

S06.895D

S06.895S

S06.896A

S06.896D

S06.896S

S06.897A

S06.898A

S06.899A

S06.899D

S06.899S

S06.9X0A

S06.9X0D

S06.9X0S

S06.9X1A

S06.9X1D

S06.9X1S

S06.9X2A

S06.9X2D

S06.9X2S

S06.9X3A

S06.9X3D

S06.9X3S

S06.9X4A

S06.9X4D

S06.9X4S

S06.9X5A

S06.9X5D

S06.9X5S

S06.9X6A

S06.9X6D

S06.9X6S

S06.9X7A

S06.9X8A

S06.9X9A

S06.9X9D

S06.9X9S

S12.000A

S12.000B

S12.000S

S12.001A

S12.001B

S12.001S

S12.01XS

S12.02XS

S12.030S

S12.031S

S12.040S

S12.041S

S12.090S

S12.091S

S12.100A

S12.100B

S12.100S

S12.101A

S12.101B

S12.101S

S12.110A

S12.110B

S12.110S

S12.111A

S12.111B

S12.111S

S12.112A

S12.112B

S12.112S

S12.120A

S12.120B

S12.120S

S12.130A

S12.130B

S12.130S

S12.131A

S12.131B

S12.131S

S12.14XA

S12.14XB

S12.14XS

S12.150A

S12.150B

S12.150S

S12.151A

S12.151B

S12.151S

S12.190A

S12.190B

S12.190S

S12.191A

S12.191B

S12.191S

S12.200A

S12.200B

S12.200S

S12.201A

S12.201B

S12.201S

S12.230A

S12.230B

S12.230S

S12.231A

S12.231B

S12.231S

S12.24XA

S12.24XB

S12.24XS

S12.250A

S12.250B

S12.250S

S12.251A

S12.251B

S12.251S

S12.290A

S12.290B

S12.290S

S12.291A

S12.291B

S12.291S

S12.300A

S12.300B

S12.300S

S12.301A

S12.301B

S12.301S

S12.330A

S12.330B

S12.330S

S12.331A

S12.331B

S12.331S

S12.34XA

S12.34XB

S12.34XS

S12.350A

S12.350B

S12.350S

S12.351A

S12.351B

S12.351S

S12.390A

S12.390B

S12.390S

S12.391A

S12.391B

S12.391S

S12.400A

S12.400B

S12.400S

S12.401A

S12.401B

S12.401S

S12.430A

S12.430B

S12.430S

S12.431A

S12.431B

S12.431S

S12.44XA

S12.44XB

S12.44XS

S12.450A

S12.450B

S12.450S

S12.451A

S12.451B

S12.451S

S12.490A

S12.490B

S12.490S

S12.491A

S12.491B

S12.491S

S12.500A

S12.500B

S12.500S

S12.501A

S12.501B

S12.501S

S12.530A

S12.530B

S12.530S

S12.531A

S12.531B

S12.531S

S12.54XA

S12.54XB

S12.54XS

S12.550A

S12.550B

S12.550S

S12.551A

S12.551B

S12.551S

S12.590A

S12.590B

S12.590S

S12.591A

S12.591B

S12.591S

S12.600A

S12.600B

S12.600S

S12.601A

S12.601B

S12.601S

S12.630A

S12.630B

S12.630S

S12.631A

S12.631B

S12.631S

S12.64XA

S12.64XB

S12.64XS

S12.650A

S12.650B

S12.650S

S12.651A

S12.651B

S12.651S

S12.690A

S12.690B

S12.690S

S12.691A

S12.691B

S12.691S

S12.9XXA

S12.9XXD

S12.9XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118D

S14.118S

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128D

S14.128S

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151S

S14.152A

S14.152S

S14.153A

S14.153S

S14.154A

S14.154S

S14.155A

S14.155S

S14.156A

S14.156S

S14.157A

S14.157S

S14.158A

S14.158S

S14.159A

S14.159S

S14.2XXA

S14.2XXS

S14.3XXA

S14.3XXS

S14.4XXA

S14.4XXS

S14.5XXA

S14.5XXS

S22.000A

S22.000B

S22.000S

S22.001A

S22.001B

S22.001S

S22.002A

S22.002B

S22.002S

S22.008A

S22.008B

S22.008S

S22.009A

S22.009B

S22.009S

S22.010A

S22.010B

S22.010S

S22.011A

S22.011B

S22.011S

S22.012A

S22.012B

S22.012S

S22.018A

S22.018B

S22.018S

S22.019A

S22.019B

S22.019S

S22.020A

S22.020B

S22.020S

S22.021A

S22.021B

S22.021S

S22.022A

S22.022B

S22.022S

S22.028A

S22.028B

S22.028S

S22.029A

S22.029B

S22.029S

S22.030A

S22.030B

S22.030S

S22.031A

S22.031B

S22.031S

S22.032A

S22.032B

S22.032S

S22.038A

S22.038B

S22.038S

S22.039A

S22.039B

S22.039S

S22.040A

S22.040B

S22.040S

S22.041A

S22.041B

S22.041S

S22.042A

S22.042B

S22.042S

S22.048A

S22.048B

S22.048S

S22.049A

S22.049B

S22.049S

S22.050A

S22.050B

S22.050S

S22.051A

S22.051B

S22.051S

S22.052A

S22.052B

S22.052S

S22.058A

S22.058B

S22.058S

S22.059A

S22.059B

S22.059S

S22.060A

S22.060B

S22.060S

S22.061A

S22.061B

S22.061S

S22.062A

S22.062B

S22.062S

S22.068A

S22.068B

S22.068S

S22.069A

S22.069B

S22.069S

S22.070A

S22.070B

S22.070S

S22.071A

S22.071B

S22.071S

S22.072A

S22.072B

S22.072S

S22.078A

S22.078B

S22.078S

S22.079A

S22.079B

S22.079S

S22.080A

S22.080B

S22.080S

S22.081A

S22.081B

S22.081S

S22.082A

S22.082B

S22.082S

S22.088A

S22.088B

S22.088S

S22.089A

S22.089B

S22.089S

S24.0XXA

S24.0XXS

S24.101A

S24.101S

S24.102A

S24.102S

S24.103A

S24.103S

S24.104A

S24.104S

S24.109A

S24.109S

S24.111A

S24.111S

S24.112A

S24.112S

S24.113A

S24.113S

S24.114A

S24.114S

S24.119A

S24.119S

S24.131A

S24.131S

S24.132A

S24.132S

S24.133A

S24.133S

S24.134A

S24.134S

S24.139A

S24.139S

S24.141A

S24.141S

S24.142A

S24.142S

S24.143A

S24.143S

S24.144A

S24.144S

S24.149A

S24.149S

S24.151A

S24.151S

S24.152A

S24.152S

S24.153A

S24.153S

S24.154A

S24.154S

S24.159A

S24.159S

S24.2XXA

S24.2XXS

S32.000A

S32.000B

S32.000S

S32.001A

S32.001B

S32.001S

S32.002A

S32.002B

S32.002S

S32.008A

S32.008B

S32.008S

S32.009A

S32.009B

S32.009S

S32.010A

S32.010B

S32.010S

S32.011A

S32.011B

S32.011S

S32.012A

S32.012B

S32.012S

S32.018A

S32.018B

S32.018S

S32.019A

S32.019B

S32.019S

S32.020A

S32.020B

S32.020S

S32.021A

S32.021B

S32.021S

S32.022A

S32.022B

S32.022S

S32.028A

S32.028B

S32.028S

S32.029A

S32.029B

S32.029S

S32.030A

S32.030B

S32.030S

S32.031A

S32.031B

S32.031S

S32.032A

S32.032B

S32.032S

S32.038A

S32.038B

S32.038S

S32.039A

S32.039B

S32.039S

S32.040A

S32.040B

S32.040S

S32.041A

S32.041B

S32.041S

S32.042A

S32.042B

S32.042S

S32.048A

S32.048B

S32.048S

S32.049A

S32.049B

S32.049S

S32.050A

S32.050B

S32.050S

S32.051A

S32.051B

S32.051S

S32.052A

S32.052B

S32.052S

S32.058A

S32.058B

S32.058S

S32.059A

S32.059B

S32.059S

S32.10XA

S32.10XB

S32.10XS

S32.110A

S32.110B

S32.110S

S32.111A

S32.111B

S32.111S

S32.112A

S32.112B

S32.112S

S32.119A

S32.119B

S32.119S

S32.120A

S32.120B

S32.120S

S32.121A

S32.121B

S32.121S

S32.122A

S32.122B

S32.122S

S32.129A

S32.129B

S32.129S

S32.130A

S32.130B

S32.130S

S32.131A

S32.131B

S32.131S

S32.132A

S32.132B

S32.132S

S32.139A

S32.139B

S32.139S

S32.14XA

S32.14XB

S32.14XS

S32.15XA

S32.15XB

S32.15XS

S32.16XA

S32.16XB

S32.16XS

S32.17XA

S32.17XB

S32.17XS

S32.19XA

S32.19XB

S32.19XS

S32.2XXA

S32.2XXB

S32.2XXS

S34.01XA

S34.01XS

S34.02XA

S34.02XS

S34.101A

S34.101S

S34.102A

S34.102S

S34.103A

S34.103S

S34.104A

S34.104S

S34.105A

S34.105S

S34.109A

S34.109S

S34.111A

S34.111S

S34.112A

S34.112S

S34.113A

S34.113S

S34.114A

S34.114S

S34.115A

S34.115S

S34.119A

S34.119S

S34.121A

S34.121S

S34.122A

S34.122S

S34.123A

S34.123S

S34.124A

S34.124S

S34.125A

S34.125S

S34.129A

S34.129S

S34.131A

S34.131S

S34.132A

S34.132S

S34.139A

S34.139S

S34.21XA

S34.21XS

S34.22XA

S34.22XS

S34.3XXA

S34.3XXS

S34.4XXA

S34.4XXS

S44.00XA

S44.00XS

S44.01XA

S44.01XS

S44.02XA

S44.02XS

S44.10XA

S44.10XS

S44.11XA

S44.11XS

S44.12XA

S44.12XS

S44.20XA

S44.20XS

S44.21XA

S44.21XS

S44.22XA

S44.22XS

S44.30XA

S44.30XS

S44.31XA

S44.31XS

S44.32XA

S44.32XS

S44.40XA

S44.40XS

S44.41XA

S44.41XS

S44.42XA

S44.42XS

S44.50XA

S44.50XS

S44.51XA

S44.51XS

S44.52XA

S44.52XS

S44.8X1A

S44.8X1S

S44.8X2A

S44.8X2S

S44.8X9A

S44.8X9S

S44.90XA

S44.90XS

S44.91XA

S44.91XS

S44.92XA

S44.92XS

S54.00XA

S54.00XS

S54.01XA

S54.01XS

S54.02XA

S54.02XS

S54.10XA

S54.10XS

S54.11XA

S54.11XS

S54.12XA

S54.12XS

S54.20XA

S54.20XS

S54.21XA

S54.21XS

S54.22XA

S54.22XS

S54.30XA

S54.30XS

S54.31XA

S54.31XS

S54.32XA

S54.32XS

S54.8X1A

S54.8X1S

S54.8X2A

S54.8X2S

S54.8X9A

S54.8X9S

S54.90XA

S54.91XA

S54.92XA

S64.00XA

S64.00XS

S64.01XA

S64.01XS

S64.02XA

S64.02XS

S64.10XA

S64.10XS

S64.11XA

S64.11XS

S64.12XA

S64.12XS

S64.20XA

S64.20XS

S64.21XA

S64.21XS

S64.22XA

S64.22XS

S64.30XA

S64.30XS

S64.31XA

S64.31XS

S64.32XA

S64.32XS

S64.40XA

S64.40XS

S64.490A

S64.490S

S64.491A

S64.491S

S64.492A

S64.492S

S64.493A

S64.493S

S64.494A

S64.494S

S64.495A

S64.495S

S64.496A

S64.496S

S64.497A

S64.497S

S64.498A

S64.498S

S64.8X1A

S64.8X1S

S64.8X2A

S64.8X2S

S64.8X9A

S64.8X9S

S64.90XA

S64.90XS

S64.91XA

S64.91XS

S64.92XA

S64.92XS

S74.00XA

S74.00XS

S74.01XA

S74.01XS

S74.02XA

S74.02XS

S74.10XA

S74.10XS

S74.11XA

S74.11XS

S74.12XA

S74.12XS

S74.20XA

S74.20XS

S74.21XA

S74.21XS

S74.22XA

S74.22XS

S74.8X1A

S74.8X1S

S74.8X2A

S74.8X2S

S74.8X9A

S74.8X9S

S74.90XA

S74.90XS

S74.91XA

S74.91XS

S74.92XA

S74.92XS

S84.00XA

S84.00XS

S84.01XA

S84.01XS

S84.02XA

S84.02XS

S84.10XA

S84.10XS

S84.11XA

S84.11XS

S84.12XA

S84.12XS

S84.20XA

S84.20XS

S84.21XA

S84.21XS

S84.22XA

S84.22XS

S84.801A

S84.801S

S84.802A

S84.802S

S84.809A

S84.809S

S84.90XA

S84.90XS

S84.91XA

S84.91XS

S84.92XA

S84.92XS

S94.00XA

S94.00XS

S94.01XA

S94.01XS

S94.02XA

S94.02XS

S94.10XA

S94.10XS

S94.11XA

S94.11XS

S94.12XA

S94.12XS

S94.20XA

S94.20XS

S94.21XA

S94.21XS

S94.22XA

S94.22XS

S94.30XA

S94.30XS

S94.31XA

S94.31XS

S94.32XA

S94.32XS

S94.8X1A

S94.8X1S

S94.8X2A

S94.8X2S

S94.8X9A

S94.8X9S

S94.90XA

S94.90XS

S94.91XA

S94.91XS

S94.92XA

S94.92XS

T68.XXXA

T68.XXXD

T68.XXXS

T84.216A

T84.216D

T84.216S

T84.226A

T84.226D

T84.226S

T84.296A

T84.296D

T84.296S

T84.310A

T84.310D

T84.310S

T84.318A

T84.318D

T84.318S

T84.320A

T84.320D

T84.320S

T84.328A

T84.328D

T84.328S

T84.390A

T84.390D

T84.390S

T84.398A

T84.398D

T84.398S

Z45.41

Z45.42

Z45.49

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-21-20 Revised policy

Updated language

Internal Medical Policy Committee 1-19-2021 Coding update:

Removed Procedure codes 92585; and 92586; and
Added Procedure codes 92650; 92651; 92652; and 92653

Internal Medical Policy Committee 9-21-2021 Coding update;

Added Diagnosis codes H81.41; H81.42; H81.43; H81.49; and H83.19

Internal Medical Policy Committee 9-28-2022 Revision of Policy

Removed Procedure code 95941 and 95942
Updated language throughout policy

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