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Clinical Policy Title: Somatosensory evoked potentials test

Clinical Policy Number: 1033

Effective Date: January 1, 2016

Initial Review Date: June 16, 2013

Most Recent Review Date: August 1, 2018

Next Review Date: August 2019

Related policies:

None.

ABOUT THIS POLICY: AmeriHealth Caritas has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas’ clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas’ clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas’ clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas will update its clinical policies as necessary. AmeriHealth Caritas’ clinical policies are not guarantees of payment.

Coverage policy

AmeriHealth Caritas considers the use of short-latency somatosensory evoked potential testing to be

clinically proven and therefore, medically necessary when the following criteria are met (Achouh, 2007;

Hayes, 2016; Liu, 2017; Tanaka, 2016; Thirumala, 2016; Thirumala, 2017):

To assess any neurologic decline which may warrant emergent surgery in unconscious spinal

cord injury members who show specific structural damage to the somatosensory system, and

who are candidates for emergency spinal cord surgery (Tanaka, 2016).

For diagnosis and management of specific neurologic diseases which involve the somatosensory

system, conditions such as multiple sclerosis, spinal cord trauma, myoclonus and Pelizaeus-

Merzbacher disease.

Intraoperative monitoring during surgeries that place parts of the somatosensory pathways at

risk (Achouh, 2007; Hayes, 2016; Liu, 2017, Thirumala, 2016a; 2016b; 2016c; 2016d; Thirumala,

2017 )

To evaluate members with sensory symptoms that might be psychogenic.

Policy contains:

Somatosensory evoked

potentials test.

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To localize the cause of a central nervous system deficit seen on exam, but not explained by

lesions seen on computerized tomography or magnetic resonance imaging.

To manage members with spinocerebellar degeneration (e.g., Friedreich’s ataxia,

olivopontocerebellar degeneration).

Unexplained myelopathy.

To evaluate members with suspected brain death.

All medical necessity criteria must be clearly documented in the member's medical record and

made available upon request.

Limitations: AmeriHealth Caritas considers all other uses of somatosensory evoked potentials testing not medically

necessary.

Note: Somatosensory evoked potentials studies are appropriate only when a detailed clinical history,

neurologic examination and appropriate diagnostic tests, such as imaging studies, electromyogram, and

nerve conduction studies make a lesion (or lesions) of the central somatosensory pathways a likely and

reasonable differential diagnostic possibility.

Alternative covered services:

Conventional nerve conduction studies or needle electromyography, as ordered, under care of a primary

care physician or neurologist.

Background

Somatosensory evoked potentials testing studies the relay of body sensations to the brain and how the

brain receives those sensations. A stimulating electrode is placed on the arm or leg, and it generates an

electrical signal. Recording electrodes are placed on the head and/or spine. The information received

from these electrodes can help to diagnose a problem.

The test evaluates the health of peripheral nerves and the spinal cord. It also tests how the spinal cord

and/or brain transmit information about body sensations through peripheral nerves. It can localize a

"signal blockage" either in the relay system, (peripheral nerves act like telephone wires) or in the

interpretive center (the brain and spinal cord act like a telephone receiver).

Evoked potentials studies involve three major tests that measure response to visual, auditory and

electrical stimuli.

Visual evoked response test. This test can diagnose problems with the optic nerves that affect

sight. Electrodes are placed along the scalp. The patient is asked to watch a checkerboard

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pattern flash for several minutes on a screen and the electrical responses in the brain are

recorded.

Brainstem auditory evoked response test. This test can diagnose hearing ability and can indicate

the presence of brain stem tumors and multiple sclerosis. Electrodes are placed on the scalp and

earlobes. Auditory stimuli, such as clicking noises and tones, are delivered to one ear.

Somatosensory evoked response test. This test can detect problems with the spinal cord as well

as numbness and weakness of the extremities. For this test, electrodes are attached to the wrist,

the back of the knee, or other locations. A mild electrical stimulus is applied through the

electrodes. Electrodes on the scalp then determine the amount of time it takes for the current

to travel along the nerve to the brain.

A related procedure is the electroencephalogram, which measures spontaneous electrical activity of the

brain. Please see this procedure for additional information. Evoked potential studies may be used to

assess hearing or sight, especially in infants and children, to diagnose disorders of the optic nerve, and

to detect tumors or other problems affecting the brain and spinal cord. The tests may also be performed

to assess brain function during a coma.

A disadvantage of these tests is that they detect abnormalities in sensory function, but usually do not

produce a specific diagnosis about what is causing the abnormality. However, the evoked potentials test

can sometimes confirm a diagnosis of multiple sclerosis.

Searches

AmeriHealth Caritas searched PubMed and the databases of:

• UK National Health Services Centre for Reviews and Dissemination.

• Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidence-

based practice centers.

• The Centers for Medicare & Medicaid Services.

We conducted searches on June 12, 2018. Search terms were: evoked potentials MeSH, intraoperative

MeSH, spinal cord MeSH, Neuropathy MeSH and plexopathy MeSH.

We included:

• Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and

greater precision of effect estimation than in smaller primary studies. Systematic reviews use

predetermined transparent methods to minimize bias, effectively treating the review as a

scientific endeavor, and are thus rated highest in evidence-grading hierarchies.

• Guidelines based on systematic reviews.

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• Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost

studies), reporting both costs and outcomes — sometimes referred to as efficiency studies —

which also rank near the top of evidence hierarchies.

Findings

Somatosensory evoked potential tests are used for clinical diagnosis in patients with neurologic

diseases, to evaluate patients with sensory symptoms that might be psychogenic, for prognostication in

comatose patients, and for intraoperative monitoring during surgeries, that place parts of the

somatosensory pathways at risk.

Abnormal findings can result from dysfunction at the level of the peripheral nerve, plexus, spinal root,

spinal cord, brain stem, thalamocortical projections, or primary somatosensory cortex. Since individuals

have multiple parallel afferent somatosensory pathways, (e.g., the anterior spinothalamic tract and the

dorsal column tracts within the spinal cord), somatosensory evoked potential testings can be normal in

patients with significant sensory deficits. However, an abnormal somatosensory evoked potential test

result demonstrates that there is dysfunction within the somatosensory pathways.

Subjects cannot volitionally make their somatosensory evoked potentials. Abnormal results are useful in

identifying clinically apparent abnormalities and lesions causing only vague or equivocal signs or

symptoms, and offer a noninvasive, often quantifiable, method of assessing known lesions.

Somatosensory evoked potential testing may also be useful for certain conditions in which the diagnosis

is uncertain, by indicating involvement of central somatosensory pathways, as well as suggesting the

type of involvement (e.g., demyelination).

For patients with cervical root disease, electromyography and nerve conduction studies remain the gold

standard diagnostic tests, though their prognostic value is limited. For patients with suspected cervical

myelopathy, somatosensory evoked potentials tests are more accurate in differentiating anterior horn

cell diseases from myelopathy. For patients with diabetes peripheral neuropathy, adding motor evoked

potentials testing is useful.

Policy updates:

A systematic review (Liu, 2017) evaluated the intraoperative warning criteria for monitoring evoked

potential. Current guidelines recommend a decrease in somatosensory evoked potentials amplitude by

50 percent and motor evoked potentials amplitude by 50 percent through 100 percent as warning

signals for injury to the ascending sensory and descending motor pathways. Of significance, 0.1 percent

through 4.1 percent of monitored patients in the review suffered postoperative neurologic deficit

despite apparently normal intraoperative recordings. The authors argue that until a threshold that

predicts spinal cord injury can be accurately determined, it remains difficult to define the clinical utility

of intraoperative neurophysiologic monitoring.

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A systematic review (Thirumala, 2017) sought to determine the efficacy of intraoperative transcranial

motor evoked potential (in patients (n=2102) undergoing surgery for scoliosis, and found an observed

incidence of neurological deficits of 1.38 percent (29/2102). The diagnostic odds ratio indicated that it is

250 times more likely to observe significant motor evoked potentials changes intra-operatively in

patients who experience a new-onset motor deficit immediately after scoliosis surgery.

A systematic review (Thirumala 2016a) studied the predictive value of combined multimodality SSEP and

transcranial motor evoked potential monitoring in detecting impending neurological injury during

surgery for idiopathic scoliosis. Seven studies (n=2052) established the incidence of neurological deficit

in this cohort was 0.93 percent. The pooled sensitivity, specificity, and diagnostic odds ratio were 82.6

percent (95% CI 56.7%-94.5%), 94.4 percent (95% CI 85.1%-98.0%), and 106.16 (95% CI 24.952-451.667),

respectively. The authors reported that patients who experience a new neurological deficit discovered

postoperatively are 106.16 times more likely to have had an somatosensory and/or transcranial motor

evoked potentials change during corrective procedures, and that these results demonstrate that

combined multimodality somatosensory and transcranial motor evoked potentials monitoring are

advantageous in this clinical setting.

A contemporary meta-analysis (Tanaka 2016) found motor evoked potentials monitoring intra-

operatively to be high in sensitivity and specificity at predicting postoperative paraplegia in patients

undergoing thoracic (TA) or thoracoabdominal aortic aneurysm (TAAA) surgery.

A systematic review (Thirumala 2016b) considered the ability of intraoperative SSEP to predict

perioperative neurological outcome in patients undergoing spinal deformity surgery to correct

adolescent idiopathic scoliosis (AIS). Fifteen studies (n=4763) documented new postoperative

neurological deficits in 1.11 percent (53/4763) of the sample population. Among this population, 75.5

percent (40/53) showed significant somatosensory evoked potentials changes, and 24.5 percent (13/53)

did not show significant change (average 84%, 95% confidence interval (CI) 59-95%) and specificity

(average 98%, 95% CI 97-99%). The diagnostic odds ratio was 340 (95% CI 125-926). The authors

concluded that somatosensory evoked potentials is a highly sensitive and specific test, and that

iatrogenic spinal cord injury resulting in new neurological deficits was 340 times more likely to have

changes in SSEP compared to those without any new deficits.

A systematic review (Thirumala 2016c) sought to determine whether intraoperative changes in

somatosensory evoked potentials during cerebral aneurysm clipping are predictive of perioperative

stroke. A total of 14 articles (n=2015) found somatosensory evoked potentials demonstrated a strong

mean specificity of 84.5% (95% confidence interval [95% CI] -76.3 to 90.3). However, there was

significantly less sensitivity of 56.8% (95% CI 44.1-68.6) for predicting stroke. A diagnostic odds ratio of

7.772 (95% CI 5.133-11.767) suggested that the odds of observing a change among those with a

postoperative neurologic deficit were 7 to 8 times greater than those without a neurologic deficit.

A systematic review (Thirumala, 2016d) studied somatosensory evoked potentials, transcranial motor

evoked potentials, and electromyography as monitoring activities in anterior cervical procedures for

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cervical spondylotic myelopathy. The authors identified a total of only two studies (n=173) that met

inclusion criteria for the review. In both studies, procedures done without monitoring found worsening

myelopathy and/or quadriplegia: 2.71 percent of patients without monitoring and 0.91 percent of

patients with monitoring. The authors opined that insufficient evidence exists to make

recommendations regarding the use of different monitoring modalities to reduce neurological

complications during anterior cervical procedures.

A clinical trial (Achouh, 2007) found intraoperative somatosensory evoked potentials monitoring was

reliable (though low in sensitivity) in ruling out spinal injury in descending thoracoabdominal aneurysm

and thoracoabdominal aortic aneurysm repair. Moreover, the modality was an independent predictor of

mortality and correlated well with low preoperative glomerular filtration rate.

A Hayes review of multimodal intraoperative monitoring during cervical spinal surgery found low-quality

evidence suggesting both sensitivity and specificity in predicting postoperative injury, that included

immediate C5 nerve root damage (Hayes, 2016a). The overall quality of the evidence pertaining to the

diagnostic accuracy (i.e., clinical validity) of multimodal intraoperative monitoring in detecting

neurological deficits was rated as low. Only two of the included studies were considered to be of fair

quality, with seven considered to be of poor quality. The overall quality of the evidence related to the

clinical utility of multimodal intraoperative monitoring was rated as very low because all three studies

directly measuring clinical utility had serious limitations in terms of study design and conduct, which

may have introduced important differences between the groups, affecting the results observed. Hayes

established a rating of C (potential but unproven benefit) for this technology.

Moderate-quality evidence suggests that monitoring during corrective surgery for scoliosis is accurate in

identifying patients who experience neurological decline during surgery, and is assumed to have clinical

utility (Hayes, 2016b). It is in contemporary practice a useful adjunct to prevent permanent neurological

damage. Hayes has established a rating of B (some proven benefit) for this intervention.

In 2018, we added two publications (one guideline and one peer-reviewed article) to the reference list

(Metwali, 2018; Robson, 2018). No policy changes are warranted at this time. Policy ID changed from

09.01.10 to CCP.1033.

Summary of clinical evidence:

Citation Content, Methods, Recommendations

Liu (2017)

Warning criteria for

intraoperative

neurophysiologic monitoring.

Key points:

A systematic review evaluated the intraoperative warning criteria for intraoperative

evoked potential.

Current guidelines recommend a decrease in somatosensory evoked potentials

amplitude by 50 percent and motor evoked potentials amplitude by 50 percent

through 100 percent as warning signals for injury to the ascending sensory and

descending motor pathways.

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Citation Content, Methods, Recommendations

Of significance, 0.1 percent through 4.1 percent of monitored patients in the review

suffered postoperative neurologic deficit despite apparently normal intraoperative

recordings.

The authors argue that until a threshold that predicts spinal cord injury can be

accurately determined, it remains difficult to define the clinical utility of

intraoperative neurophysiologic monitoring.

Thirumala (2017)

Diagnostic accuracy of motor

evoked potentials to detect

neurological deficit during

idiopathic scoliosis correction:

a systematic review.

Key points:

A systematic review sought to determine the efficacy of intraoperative motor evoked

potentials in patients (n=2102) undergoing surgery for scoliosis, and found an

observed incidence of neurological deficits of 1.38 percent (29/2102).

The diagnostic odds ratio indicated that it is 250 times more likely to observe

significant motor evoked potentials changes in patients who experience a new-

onset motor deficit immediately after scoliosis surgery.

Thirumala (2016a)

Diagnostic accuracy of

combined multimodality

somatosensory evoked

potential and transcranial

motor evoked potential

intraoperative monitoring in

patients with idiopathic

scoliosis

Key points:

Systematic review of 7 publications (total sample 2,052) on patients with surgery for

idiopathic scoliosis resulted in a diagnostic odds ratio of 106.16 (95% CI 24.952,

451.667). Interpretation: those with a new neurological deficit were about 106 times

as likely to have had intrasurgical changes.

Conclusion: combined monitoring shows an advantage over single mode

monitoring, and intrasurgical monitoring may be valuable in predicting a new

neurological deficit.

Thirumala (2016b)

Diagnostic accuracy of

somatosensory evoked

potential monitoring during

scoliosis fusion.

Key points:

A systematic review considered the ability of intraoperative SSEP to predict

perioperative neurological outcome in patients undergoing spinal deformity surgery

to correct adolescent idiopathic scoliosis (AIS).

Fifteen studies (n=4763) documented new postoperative neurological deficits in

1.11 percent (53/4763) of the sample population.

Among this population, 75.5 percent (40/53) showed significant SSEP changes,

and 24.5 percent (13/53) did not show significant change (average 84%, 95%

confidence interval 59-95%) and specificity (average 98%, 95% confidence interval

97-99%).

The diagnostic odds ratio was 340 (95% confidence interval 125-926). The authors

concluded that SSEP is a highly sensitive and specific test, and that iatrogenic

spinal cord injury resulting in new neurological deficits was 340 times more likely to

have changes in SSEP compared to those without any new deficits.

Thirumala (2016c)

Diagnostic value of

somatosensory-evoked

potential monitoring during

cerebral aneurysm clipping

Key points:

Systematic review of 14 publications (total sample 2,015) on SSEP monitoring

during cerebral aneurism clipping resulted in a diagnostic odds ratio of 7.772 (95%

CI -76.3, 90.3). Interpretation: among those with a neurologic deficit, the odds of

observing a change in SSEP were nearly 8 times more than among those without a

neurologic deficit.

Conclusion: among patients undergoing surgery for clipping of cerebral aneurisms,

SSEP monitoring during surgery is “highly specific for predicting neurologic

outcome.”

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Citation Content, Methods, Recommendations

Thirumala (2016d) Value of

intraoperative

neurophysiological monitoring

to reduce neurological

complications in patients

undergoing anterior cervical

spine procedures for cervical

spondylotic myelopathy.

Key points:

A systematic review studied SSEP, TME and electromyography as monitoring

modalities in anterior cervical procedures for cervical spondylotic myelopathy.

A total of only 2 studies (n=173). In both studies procedures done without

monitoring found worsening myelopathy and/or quadriplegia as seen in 2.71

percent of patients for studies without monitoring and 0.91 percent of patients for

studies with monitoring.

The authors opined that insufficient evidence exists to make recommendations

regarding the use of different monitoring modalities to reduce neurological

complications during anterior cervical procedures.

Hayes (2016a)

Multimodal intraoperative

monitoring (MIOM) during

cervical spinal surgery

Key points:

A Hayes review of multimodal intraoperative monitoring during cervical spinal

surgery found low-quality evidence suggesting both sensitivity and specificity in

predicting postoperative injury, which included immediate C5 nerve root damage.

The overall quality of the evidence pertaining to the diagnostic accuracy (i.e.,

clinical validity) of multimodal intraoperative monitoring in detecting neurological

deficits was rated as low.

The overall quality of the evidence related to the clinical utility of MIOM was rated

as very low because all 3 studies directly measuring clinical utility had serious

limitations in terms of study design and conduct, which may have introduced

important differences between the groups, affecting the results observed.

Hayes established a rating of C (potential but unproven benefit) for this technology.

Hayes (2016b)

Multimodality intraoperative

monitoring (MIOM) during

corrective surgery for scoliosis

and spinal deformities

Key points:

Moderate-quality evidence in an Hayes review suggests that monitoring during

corrective surgery for scoliosis is accurate in identifying patients who experience

neurological decline during surgery

It is in contemporary practice a useful adjunct to prevent permanent neurological

damage. Hayes established a rating of B (some proven benefit).

Tanaka (2016)

Motor evoked potentials

monitoring during thoracic and

thoracoabdominal aortic

aneurysm open repair surgery

surgery

Key points:

Meta-analysis including 19 studies resulted in findings of 89.1 % sensitivity (95%

CI, 47.9 - 98.6 %) and 99.3 % specificity (95% CI 96.1-99.9 %) in predicting

postoperative paraplegia.

Achouh (2007)

Role of somatosensory

evoked potentials in predicting

outcome during

thoracoabdominal aortic

repair.

Key points:

A clinical trial (n=444) examined the use of somatosensory evoked potentials during

descending thoracic and thoracoabdominal aortic repair.

There were 270 thoracoabdominal aorta and 174 descending thoracic aorta

diagnoses.

Somatosensory evoked potentials changes were classified as (1) no change, (2)

transient changes that returned to baseline by the end of the procedure, or (3)

persistent changes that did not return to baseline by the end of the procedure.

Changes occurred in 87 (19.6%) patients; 22 (25%) of these did not return to

baseline.

Immediate neurologic deficit occurred in 8 of 444 patients (1.8%); five deficits (5 of

87; 5.8%) occurred in patients with somatosensory evoked potentials changes,

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Citation Content, Methods, Recommendations

compared with three deficits (3 of 357; 0.8%) in patients without changes.

The odds ratio for this comparison was 7.2 (p < 0.002).

Somatosensory evoked potential was a poor screening tool for neurologic deficit,

with a sensitivity of 62.5% and specificity 81.2%.

Negative predictive value was 99.2%, indicating a very low event probability in the

absence of somatosensory evoked potentials changes.

Delayed neurologic deficit occurred in 3.2% and was not related to somatosensory

evoked potentials changes. Somatosensory evoked potential changes were also

associated with increased 30-day mortality and low glomerular filtration rate.

The authors concluded that intraoperative somatosensory evoked potentials

monitoring was reliable in ruling out spinal injury in descending thoracic and

thoracoabdominal aortic repair, but had a low sensitivity and did not predict delayed

neurologic deficit.

Spinal somatosensory evoked potentials change was an independent predictor of

mortality and correlated with low preoperative glomerular filtration rate.

References

Professional society guidelines/ other:

Hayes Medical Technology Directory. Multimodal intraoperative monitoring (MIOM) during cervical

spinal surgery. Lansdale, Pa. Hayes Inc.; October 2016a.

Hayes Medical Technology Directory. Multimodality intraoperative monitoring (MIOM) during corrective

surgery for scoliosis and spinal deformities. Lansdale, Pa. Hayes Inc.; October 2016b.

Robson AG, Nilsson J, Li S, et al. ISCEV guide to visual electrodiagnostic procedures. Doc Ophthalmol.

2018;136(1):1-26.

Peer-reviewed references:

Achouh PE, Estrera AL, Miller CC 3rd, Azizzadeh A, Irani A, Wegryn TL, Safi HJ. Role of somatosensory

evoked potentials in predicting outcome during thoracoabdominal aortic repair. Ann Thorac Surg.

2007;84(3):782-7; discussion 787-8.

Kamen, Gary. Electromyographic Kinesiology. In Robertson, DGE et al. Research Methods in

Biomechanics. Champaign, IL: Human Kinetics Publ.; 2004.

Liu Q, Wang Q, Liu H, Wu WKK, Chan MTV. Warning criteria for intraoperative neurophysiologic

monitoring. Curr Opin Anaesthesiol. 2017;30(5):557-562.

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Metwali H, Kniese K, Fahlbusch R. Intraoperative monitoring of the integrity of the anterior visual

pathways: a methodologic review and meta-analysis. World Neurosurg. 2018;110:217-225.

Niedermeyer E. and da Silva F.L. (2004). Electroencephalography: Basic Principles, Clinical Applications,

and Related Fields. Lippincot Williams & Wilkins. ISBN 0-7817-5126-8.

Tanaka Y, Kawaguchi M, Noguchi Y, et al. Systematic review of motor evoked potentials monitoring

during thoracic and thoracoabdominal aortic aneurysm open repair surgery: a diagnostic meta-analysis.

J Anesth. 2016;30(6):1037-1050.

Thirumala PD, Cheng HL, Loke YK, Kojo Hamilton D, Balzer J, Crammond DJ. Diagnostic accuracy of

somatosensory evoked potential monitoring during scoliosis fusion. J Clin Neurosci. 2016b;30:8-14.

Thirumala PD, Crammond DJ, Loke YK, Cheng HL, Huang J, Balzer JR. Diagnostic accuracy of motor

evoked potentials to detect neurological deficit during idiopathic scoliosis correction: a systematic

review. J Neurosurg Spine. 2017;26(3):374-383.

Thirumala PD, Huang J, Thiagarajan K, Cheng H, Balzer J, Crammond DJ. Diagnostic Accuracy of

Combined Multimodality Somatosensory Evoked Potential and Transcranial Motor Evoked Potential

Intraoperative Monitoring in Patients With Idiopathic Scoliosis. Spine. 2016a;41(19):E1177-1184.

Thirumala P, Muralidharan A, Loke YK, Habeych M, Crammond D, Balzer J. Value of intraoperative

neurophysiological monitoring to reduce neurological complications in patients undergoing anterior

cervical spine procedures for cervical spondylotic myelopathy. J Clin Neurosci. 2016d;25:27-35.

Thirumala PD, Udesh R, Muralidharan A, et al. Diagnostic Value of Somatosensory-Evoked Potential

Monitoring During Cerebral Aneurysm Clipping: A Systematic Review. World Neurosurgery.

2016c;89:672-680.

CMS National Coverage Determinations:

National Coverage Determination (NCD) for Evoked Response Tests (160.10)

Local Coverage Determinations:

No Local Coverage Determinations identified as of the writing of this policy.

Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is

not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and

bill accordingly.

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CPT Code Description Comment

95925 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs

95926 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs

95927 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head

95938 Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper and lower limbs

ICD 10 Code Description Comment

G11.0 – G11.9 Hereditary ataxia

G23.0 – G23.9 Other degenerative diseases of the basal ganglia

G25.3 Myoclonus

G32.0 Subacute combined degeneration of spinal cord in diseases classified elsewhere

G32.81 Cerebellar ataxia in diseases classified elsewhere

G35 Multiple sclerosis

G36.0 – G36.9 Other acute disseminated demyelination

G37.0 – G37.9 Other demyelinating diseases of central nervous system

E75.23 Krabbe disease

E75.25 Metachromatic leukodystrophy

E75.29 Other sphingolipidosis

G82.20 Paraplegia, unspecified

G82.21 Paraplegia, complete

G82.22 Paraplegia, incomplete

G90.3 Multi-system degeneration of the autonomic nervous system

G93.0 Cerebral cysts

G93.1 Anoxic brain damage, not elsewhere classified

G93.40 – G93.49

Other and unspecified encephalopathy

G93.5 Compression of brain

G93.6 Cerebral edema

G93.82 Brain death

G93.89 Other specified disorders of brain

G93.9 Disorder of brain, unspecified

G95.0 Syringomyelia and syringobulbia

G95.20 Unspecified cord compression

G95.29 Other cord compression

G95.9 Disease of spinal cord, unspecified

I67.83 Posterior reversible encephalopathy syndrome

P11.5 Birth injury to spine and spinal cord

S06.1x0A – S06.1x9S

Traumatic cerebral edema

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HCPCS Level II Code

Description Comment

G0453

Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure