ModifiedCignaPolicy 0315

Gait Analysis (Computerized/Motion Analysis)

Provides Cigna's coverage policy for computerized gait analysis (motion analysis), including when it is considered medically necessary, coding references, and supporting clinical background; applies to services billed to Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyGait Analysis (Computerized/Motion Analysis)

Policy CodePolicy 0315

Change TypeAnnual review — material revision (added myelomeningocele)

Effective DateMay 15, 2026

Next Review DateApr 15, 2027

Key ActionObtain prior authorization documenting the patient is a child/adolescent with cerebral palsy or myelomeningocele and that the gait analysis will be used for preoperative surgical planning.

SourceLink

POLICY UPDATE CHANGES

Revised policy statement to include myelomeningocele.

No clinical policy statement changes for prior annual reviews.

2required criteria to be medically necessary

96000–96004CPT codes listed as medically necessary (examples)

G80.*, Q05.*ICD-10 diagnosis codes referenced

10minimum consecutive steps required

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Policy revised to include myelomeningocele

Coverage Criteria

inv-01: Medically Necessary — Pediatric Preoperative Indication

Covered when ALL of the following are met:

Medically necessary criteria: Patient is a child or adolescent with a diagnosis of cerebral palsy or myelomeningocele.

Diagnosis must be documented in the medical record.

Medically necessary criteria: The computerized gait analysis is performed as part of a preoperative assessment and the results will be used in surgical planning.

Testing must be explicitly intended to inform surgical decision-making and documented as part of preoperative planning.

inv-02: Not Covered / Reimbursable — Not covered when ANY of the following apply

Not covered when ANY of the following apply:

Not covered indications: Gait analysis performed for any indication other than preoperative assessment in a child or adolescent with cerebral palsy or myelomeningocele.

Includes gait analysis for other diagnoses, age groups, or non-preoperative uses; such claims are not covered or reimbursable and may be denied.

Insufficient evidence indications: Use of dynamic gait analysis for other conditions (e.g., elderly post-hip fracture, stroke, osteoarthritis, nonspecific low back pain) where evidence does not demonstrate improved long-term health outcomes.

These indications are not supported by sufficient evidence for coverage.

inv-03: Professional society recommended indications — Professional guidance supports recommending 3D-IGA in the following situations for ambulatory pediatric patients

Professional guidance supports recommending 3D-IGA in the following situations for ambulatory pediatric patients:

Surgical decision-making: Recommend 3D-IGA when a child with cerebral palsy or an ambulatory patient with spina bifida is being considered for orthopedic surgery to improve gait.

APTA Evidence Quality: II; Spina Bifida Association recommends computerized gait analysis for surgical decision-making in specified pediatric age groups.

Gait deviation analysis: Recommend 3D-IGA when gait dysfunction requires identification, quantification, and differentiation of deviations among individual segments/joints and planes (sagittal, coronal, transverse).

APTA Evidence Quality: II.

Baseline and post-intervention assessment: Recommend baseline and post-intervention 3D-IGA to evaluate biomechanical outcomes of interventions.

APTA Evidence Quality: III (rec strength upgraded to Moderate for consistent results).

Computerized gait analysis is covered only when both of the following conditions are met: (1) the patient is a child or adolescent with a diagnosis of cerebral palsy or myelomeningocele, and (2) the procedure is performed as part of a preoperative assessment and the results will be used in surgical planning. Gait analysis performed for any other indication is not covered or reimbursable.

The policy does not list additional formal exclusions beyond the narrow covered indication, but it notes practical access barriers. Claims billed without a covered diagnosis or procedure code (i.e., not matching the pediatric preoperative indication) will be denied. Additionally, socioeconomic and system-level factors may delay authorization and access to gait analysis services even when coverage criteria are met.

Dynamic (instrumented) gait analysis has been proposed and studied for a range of non‑pediatric conditions — for example, elderly patients after hip fracture, stroke, osteoarthritis, and nonspecific low back pain — but available studies are limited and do not demonstrate consistent evidence of improved long‑term health outcomes. The literature summarized here concludes there is insufficient evidence to support routine use of 3D gait analysis for these other indications.

The document does not include an explicit separate section titled "not medically necessary" within the cited chunks. It does, however, state that gait analysis for indications outside the defined pediatric preoperative context is not covered and that evidence is insufficient to support use for many other conditions.

Coding and Performance Requirements

Considered Medically Necessary CPT/Procedure CodesCPTCovered

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.
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.

Referenced ICD-10 Diagnosis CodesICD-10

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.
Q05.0	Cervical spina bifida with hydrocephalus.
Q05.1	Thoracic spina bifida with hydrocephalus.
Q05.2	Lumbar spina bifida with hydrocephalus.
Q05.3	Sacral spina bifida with hydrocephalus.

1–10 of 16

1/2

Not Covered Diagnosis CodesICD-10Not Covered

All other codes

All other ICD-10-CM diagnosis codes not listed for the covered indications.

Citations and literature (no explicit CPT/HCPCS codes in this section)mixed

No codes listed

Minimum ambulation requirement

Minimum ambulation requirementAble to walk a minimum of 10 consecutive steps

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required when the procedure meets the policy's medical necessity criteria. Authorization must document that both coverage criteria are met: (1) the member is a child or adolescent with a diagnosis of cerebral palsy or myelomeningocele, and (2) the 3D instrumented gait analysis (3D-IGA) is being performed as part of a preoperative assessment with results used for surgical planning. Claims or authorizations submitted without covered diagnosis or procedure codes will be denied.

Prior authorization required when BOTH criteria are met: covered diagnosis (CP or myelomeningocele) and preoperative surgical planning use
Claims lacking covered diagnosis/procedure codes will be denied

Prior Authorization

Prior Authorization Considerations and Access Delays

Authorization requests may be delayed or require revision when documentation is incomplete or when policy requirements are not clearly met. Delays in obtaining authorization — particularly in populations with socioeconomic barriers — can prevent timely access to gait analysis services and may result in noncoverage if criteria are not documented.

Definitions and Minimum Performance

Computerized (instrumented) gait analysis — commonly referred to as motion analysis or 3D‑IGA — measures kinematics (3‑dimensional motion capture), kinetics (force plate data), and may include dynamic electromyography (EMG) and plantar pressure measurements to evaluate complex gait abnormalities. It is intended to complement, not replace, a thorough clinical examination and is typically used to inform treatment decisions, particularly when surgical intervention is being considered.

Typical testing requires cooperative ambulation and task following; patients generally must be able to walk a minimum of 10 consecutive steps. Testing sessions commonly take approximately 2–4 hours and produce quantitative data to assist interdisciplinary teams with surgical planning and outcome assessment.

Computerized gait analysis / 3D-IGA — measurement modalities

Measurement modalitiesThree-dimensional kinematics from motion capture (video-based, reflective markers, specialized cameras)

Force/kineticsMulticomponent force platforms (force plates) embedded in the walkway to measure ground reaction forces and calculate joint loads

Electromyography (EMG)Dynamic surface or fine-wire EMG during walking to record muscle activation patterns

Background and Clinical Context

Three‑dimensional instrumented gait analysis (3D‑IGA) uses specialized video‑based motion capture systems with reflective markers to collect 3‑dimensional kinematic data, often combined with force plates for kinetic measures and dynamic EMG for muscle activation patterns. The clinical rationale for 3D‑IGA is that precise quantification of segmental and joint motion, timing, and forces can help identify the contributors to gait dysfunction, support surgical decision‑making in ambulatory pediatric neuromuscular conditions, and provide objective baseline and post‑intervention outcome data. When recommended, 3D‑IGA should be performed in laboratories capable of collecting these data and producing comprehensive, interdisciplinary reports that include referral reason, diagnosis and GMFCS level, goals, pertinent history, orthoses, physical exam findings, 3D‑IGA results, limitations/technical issues, clinician interpretation, and suggested interventions.

Revision History

2026-05-15annual_reviewLatest

Policy revised to include myelomeningocele as a covered pediatric preoperative indication for computerized gait analysis.

2025-04-15annual_review

Annual review completed with no clinical policy statement changes.

2024-04-15annual_review

Policy Summary

PayerCigna

PolicyGait Analysis (Computerized/Motion Analysis)

Policy CodePolicy 0315

Change TypeAnnual review — material revision (added myelomeningocele)

Effective DateMay 15, 2026

Next Review DateApr 15, 2027

Key ActionObtain prior authorization documenting the patient is a child/adolescent with cerebral palsy or myelomeningocele and that the gait analysis will be used for preoperative surgical planning.

SourceLink

On This Page

Non-surgical interventions: May recommend 3D-IGA to inform non-surgical interventions when progress from rehabilitative interventions has plateaued or substantially deteriorated.

APTA Evidence Quality: III; Rec. Strength: Weak.

Laboratory capabilities and reporting: When 3D-IGA is recommended, use gait laboratories capable of collecting 3-dimensional kinematic, kinetic, and EMG data and providing interdisciplinary teams and comprehensive reports.

APTA Best Practice statement: recommend laboratories that can collect kinematic, kinetic, and EMG data and provide interdisciplinary interpretation.

Authorization processes may be subject to delays and revisions if documentation is missing or unclear

Health equity and access barriers can lengthen authorization timelines and impact timely care

Documentation Required

Required Clinical Documentation

Before submitting an authorization or claim, include comprehensive clinical documentation: diagnosis (specific ICD-10 code for cerebral palsy or spina bifida/myelomeningocele), ambulatory status showing ability to walk a minimum of 10 consecutive steps (with or without assistive device), the purpose of the study (eg, preoperative planning), and evidence the patient can follow directions and cooperate during testing. Also include the planned use of results in surgical decision-making when applicable.

Document ambulatory capability: >=10 consecutive steps
Document ability to follow directions and cooperate during the procedure
Specify referral reason and intended use of results (eg, preoperative planning)
Include supported ICD-10 diagnosis codes (see coding section)

Documentation Required

Laboratory Report Expectations When 3D-IGA Is Performed

When 3D-IGA is recommended or performed, request or obtain reports from laboratories that provide comprehensive, timely, interdisciplinary documentation. Reports should include referral source and reason, diagnosis including GMFCS level when applicable, primary concerns/goals, pertinent history, current orthoses/equipment, physical exam findings, detailed 3D-IGA results, any limitations or technical issues, interpretation by licensed clinician(s) (eg, MD and/or PT), and suggested interventions.

Laboratory reports should be interdisciplinary and include referral reason, diagnosis (GMFCS level), findings, interpretations, and suggested interventions
Document any assessment limitations or technical issues in the report

Note

Conservative Care Context

Conservative care measures (eg, physical therapy, occupational therapy, casting, orthotics, medication) are generally part of standard management of cerebral palsy and spina bifida and should be documented in the clinical record. 3D-IGA is most frequently applied when surgical treatment is being considered or when progress from conservative management has plateaued or substantially deteriorated.

Document prior conservative management and response (PT, orthotics, casting, medications)
3D-IGA may be used to inform non-surgical interventions when conservative care progress has plateaued

Note

3D-IGA Recommended to Inform Surgical Decisions and Evaluations

Professional guidance supports recommending 3D-IGA to inform orthopedic surgical interventions, to analyze gait deviations by segment/plane, and to provide baseline and post-intervention biomechanical evaluation. Ensure authorization and documentation clearly state that 3D-IGA results will be used to inform surgical decision-making when that is the intent.

3D-IGA is recommended to inform orthopedic surgery planning and to evaluate baseline and post-intervention outcomes
Use laboratories capable of collecting 3D kinematic, kinetic, and EMG data and providing interdisciplinary reports

Plantar pressureDynamic plantar pressure measurements during walking (optional additional modality)

Minimum performance requirement

Ambulation thresholdIndividual must be ambulatory for at least 10 consecutive steps (with or without assistive device)

Cooperation requirementAble to follow directions and be cooperative during the procedure

Use contextTesting performed when data will inform preoperative assessment or surgical planning (per coverage criteria)

3D-IGA definition

DefinitionThree-dimensional instrumented gait analysis (3D-IGA) is analysis of 3-dimensional kinematic data from a motion capture system, often accompanied by force plates (kinetics) and electromyography (EMG)

Data captureUses multiple synchronized cameras with passive reflective markers to compute segment and joint kinematics

Complementary measuresTypically performed with force platforms to measure kinetics and optionally dynamic EMG and plantar pressure recordings

3D-IGA report components

Referral reason and sourceInclude the referral source and reason for referral

Diagnosis and GMFCS levelDocument diagnosis and Gross Motor Function Classification System (GMFCS) level

Primary goalsPrimary concerns or goals of the child, family, and treating clinicians

Pertinent history and current orthosesPertinent past medical history and current orthoses/adaptive equipment

Physical exam and 3D-IGA resultsFindings of physical exam and documentation of 3D-IGA results, including limitations or technical issues

Interpretation and intervention suggestionsInterpretation of findings by licensed clinician(s) and suggestions for interventions

Annual review completed with no clinical policy statement changes.