CurrentCignaPolicy 0315

Computerized gait analysis (motion analysis)

Defines Cigna coverage for computerized (instrumented/quantitative) gait analysis and associated dynamic EMG when used for clinical decision-making; specifies covered CPT/HCPCS and ICD-10 codes and the clinical criteria required for coverage.

Policy Summary

PayerCigna

PolicyComputerized gait analysis (motion analysis)

Policy CodePolicy 0315

Change TypeAnnual review — no clinical changes

Effective Date

Next Review Date

Key ActionProviders must document the patient is a child/adolescent with cerebral palsy and that gait analysis is part of a preoperative assessment used for surgical planning.

POLICY UPDATE CHANGES

Annual Review 4/15/2025: No clinical policy statement changes.

Annual Review 4/15/2024: No clinical policy statement changes.

1Primary Covered Indication (pediatric cerebral palsy)

>=4ICD-10 codes listed

4CPT/procedure codes listed

Coverage Summary

Scope: Defines Cigna coverage for computerized (instrumented/quantitative) gait analysis and associated dynamic EMG when used for clinical decision-making; specifies covered CPT/HCPCS and ICD-10 codes and the clinical criteria required for coverage. Coverage stance: Covered with criteria. Primary covered indication: preoperative assessment in children/adolescents with cerebral palsy (criteria require the patient be a child/adolescent with cerebral palsy and that the procedure be performed as part of preoperative assessment used in surgical planning).

Medical Necessity Criteria

Medically Necessary Criteria

Computerized gait analysis is considered medically necessary when BOTH of the following criteria are met:

Patient Population: Patient is a child or adolescent with a diagnosis of cerebral palsy.
See allowed ICD-10-CM codes G80.0, G80.1, G80.2, G80.4, G80.8, G80.9
Intended Use: The procedure is performed as part of a preoperative assessment, and the results will be used in surgical planning.
Intended application: when surgical treatment is being considered after conservative measures exhausted

Covered Codes (procedures): Considered medically necessary when criteria are met: CPT/Procedure codes 96000, 96001, 96002, 96004.

Use the most appropriate codes as of the date of service; code 96003 was deleted 12/31/2024

Not Covered

Gait analysis for indications other than the above (including adults and non-preoperative uses) is not covered or reimbursable.

Excluded Indications: Any indication other than a child/adolescent with cerebral palsy undergoing preoperative assessment for surgical planning.
All other ICD-10 diagnosis codes are not covered or reimbursable for gait analysis.

Other Conditions: Use of computerized gait analysis for conditions other than pediatric cerebral palsy (including adult pathological gait or various other proposed indications) is considered not covered due to insufficient evidence of improved long-term health outcomes.

Examples include adult gait assessments and proposed uses for osteoarthritis, stroke, achondroplasia, low back pain, clubfoot and rotational malalignment where evidence is insufficient.

Coding

Considered Medically Necessary (CPT/Procedure)CPTCovered

96000	Comprehensive computer-based motion analysis by video-taping and 3D kinematics.
96001	Comprehensive computer-based motion analysis by video-taping and 3D kinematics; with dynamic plantar pressure measurements during walking.
96002	Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles.
96003	Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle (Code deleted 12/31/2024).
96004	Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report.

Relevant ICD-10 Diagnosis Codes (Covered when criteria met)ICD-10Covered

G80.0	Spastic quadriplegic cerebral palsy.
G80.1	Spastic diplegic cerebral palsy.
G80.2	Spastic hemiplegic cerebral palsy.
G80.4	Ataxic cerebral palsy.
G80.8	Other cerebral palsy.
G80.9	Cerebral palsy, unspecified.

Not Covered Diagnosis CodesICD-10Not Covered

ALL_OTHER_CODES

All other diagnosis codes (gait analysis for indications other than those specified is not covered or reimbursable).

Provider Actions & Billing Guidance

Documentation Required

Indication and surgical planning documentation

Providers must document that the patient is a child or adolescent with cerebral palsy and that the gait analysis is being performed as part of a preoperative assessment whose results will be used in surgical planning.

Document patient age as child or adolescent and diagnosis (ICD-10 codes G80.0, G80.1, G80.2, G80.4, G80.8, G80.9).
Document that conservative treatments have been considered/exhausted and that surgical treatment is being contemplated.
Document that the gait analysis is part of a preoperative assessment and that results will be used for surgical planning.

Billing Rule

Use appropriate diagnosis and procedure codes

When billing, providers must use the most appropriate codes as of the date of service; claims for services not accompanied by covered diagnosis codes under this policy will not be reimbursed.

96000
96001
96002
96004
G80.0
G80.1
G80.2
G80.4
G80.8
G80.9

Denial Risk

Denial for other indications

Gait analysis performed for any indication other than preoperative assessment in a child/adolescent with cerebral palsy will be denied as not covered or reimbursable.

Services for adults or for non-preoperative uses, or with diagnoses other than the listed cerebral palsy codes, will be denied/not reimbursed.

Background, Evidence & Definitions

Computerized gait analysis (also called motion analysis or quantitative gait analysis) uses specialized video cameras, passive reflective markers, three-dimensional motion capture, force platforms (kinetics), and dynamic electromyography (EMG) to measure kinematics, kinetics, and muscle activation during walking. It is typically performed in a gait laboratory, takes about two to four hours, and requires the patient be ambulatory and able to follow directions. The procedure is most often used in children and adolescents with neuromuscular conditions—primarily cerebral palsy—to assist in surgical decision-making when conservative measures have been exhausted, serving as an adjunct to clinical examination and to inform which surgical procedure may be appropriate.

Evidence

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Definitions