Is medical necessity met for intraoperative monitoring (IOM) codes 95940, 95941, 95955, 95861 x2, 95999, and 95938 for a patient with spinal stenosis, lumbar region without neurogenic claudication, and radiculopathy, lumbar region?

Medical Necessity Assessment for Intraoperative Monitoring in Lumbar Stenosis Without Neurogenic Claudication

Medical necessity is NOT met for the requested intraoperative neurophysiological monitoring codes (95940,95941,95955,95861 x2, 95999,95938) in this 54-year-old female with lumbar spinal stenosis without neurogenic claudication and lumbar radiculopathy. 1

Primary Evidence Against Medical Necessity

The American Association of Neurological Surgeons guidelines explicitly state that intraoperative neurophysiological monitoring is not medically necessary for patients with lumbar spondylosis without myelopathy undergoing lumbar surgery. 1 This recommendation is based on:

• Class II evidence demonstrating that monitoring modalities have not been convincingly shown to favorably influence patient outcomes in degenerative lumbar disease 1
• High false-positive rates (4.4%) leading to unnecessary interventions without improving morbidity or mortality 1
• Limited sensitivity (only 50%) of SSEP monitoring for detecting new deficits in lumbar procedures 1

Analysis by Specific CPT Codes

CPT 95940 & 95941 (Continuous Intraoperative Monitoring)

• These codes lack evidence of benefit in routine lumbar stenosis surgery without myelopathy 1
• The high false-positive rate creates risk of unnecessary surgical alterations that do not improve outcomes 1

CPT 95955 (Electroencephalography)

• EEG monitoring lacks sufficient evidence for use in spinal surgery, including lumbar spine procedures 1
• No guideline supports EEG use for degenerative lumbar conditions 1

CPT 95861 x2 (Needle Electromyography)

• Needle EMG has insufficient evidence to provide useful information for assessing nerve root decompression in lumbar procedures 1
• While one older study from 2001 suggested potential utility 2, current evidence-based guidelines do not support routine use 1

CPT 95999 (Unlisted Neurological Procedure)

• Without specification of what this code represents, it cannot be justified when the standard monitoring modalities themselves lack medical necessity 1

CPT 95938 (Somatosensory Evoked Potentials)

• SSEPs have limited evidence of improving outcomes in lumbar procedures without myelopathy 1
• Guidelines indicate monitoring is primarily beneficial for cervical procedures or when significant cord compression is present, which is absent in this lumbar case 1

Critical Distinguishing Features of This Case

The absence of neurogenic claudication is particularly significant because:

• The diagnosis explicitly states "without neurogenic claudication," indicating less severe functional impairment 3
• Neurogenic claudication typically indicates more advanced stenosis with cauda equina compromise that might theoretically benefit from monitoring 3
• Without this feature, the risk-benefit ratio for monitoring becomes even more unfavorable 1

The presence of radiculopathy alone does not justify monitoring because:

• Radiculopathy represents nerve root involvement, not spinal cord compromise 3
• Guidelines from the Journal of Neurosurgery state that reliance on EP monitoring changes has not been observed to reduce neurological injury during routine surgery for radiculopathy 3
• The monitoring modalities requested are designed primarily for detecting spinal cord injury, not isolated nerve root injury 1

When IONM Would Be Appropriate in Lumbar Surgery

Medical necessity might be met if the patient had:

• Documented myelopathy with severe cord compression (not present in lumbar stenosis, as the spinal cord terminates at L1-L2) 4
• Tumor, intramedullary lesion, or traumatic injury (not documented) 4
• Significant deformity or instability requiring complex instrumented fusion (not indicated by the diagnoses provided) 4, 1
• Revision surgery with altered anatomy (not documented) 1

Cost-Effectiveness Considerations

• Recent 2021 research demonstrated that IONM in similar patient populations averaged $6,500 per procedure without reducing neurological deficits 5
• In that study, all new neurological deficits occurred in patients with normal IONM tracings, demonstrating lack of predictive value 5
• The study found higher incidence of new neurological deficits in monitored patients (8.0%) versus non-monitored patients (0%), suggesting potential harm from false-positive responses 5

Common Pitfall to Avoid

Do not conflate lumbar radiculopathy with cervical myelopathy when considering monitoring indications. The evidence supporting IONM in cervical procedures with myelopathy 4, 6 does not transfer to lumbar stenosis with radiculopathy, as these represent fundamentally different pathophysiological processes affecting different neural structures 3, 1.