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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence Intraop Monitoring Prior Auth | OpenPay…
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    CurrentProvidence Health PlanPolicy 296

    Intraoperative Monitoring

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    Medicare coverage, medical necessity, prior authorization, and coding requirements for intraoperative neurophysiological testing and monitoring, including continuous monitoring performed in or remotely from the operating room.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Policy Summary
    PayerProvidence Health Plan
    PolicyIntraoperative Monitoring
    Policy CodePolicy 296
    Change TypeAnnual reviewno material change
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionObtain prior authorization before service when CPT 95940 or HCPCS G0453 is billed with an Appendix I diagnosis code.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Medicare onlyProduct and benefit application
    2Codes subject to diagnosis-dependent prior authorization
    1Invalid and non-reimbursable Medicare code
    15 minG0453 billing interval
    8 minMinimum focused time for one G0453 interval
    2Policy cross references

    Coverage Criteria

    Continuous Monitoring When Medicare Criteria Are Not Fully Established

    When Medicare coverage criteria are not fully established in applicable statutes, regulations, NCDs, or LCDs, Providence Health Plan applies company medical policy criteria based on current evidence, treatment guidelines, clinical literature, and the member's circumstances.

    Company medical-policy criteria apply

    • Continuous intraoperative monitoring services billed with CPT 95940 or HCPCS G0453 are subject to the Company's medical-necessity criteria because fully established Medicare coverage criteria are not available.
    • Medical-necessity determinations consider applicable coverage and benefit criteria, current standards of care, the member's diagnoses, conditions, functional status, co-morbidities, medical history, physician recommendations, clinical notes, and plan medical-director review when appropriate.

    Not Medically Necessary Surgical Locations

    Intraoperative neurophysiological testing and monitoring is not medically necessary and is not covered in the following surgical locations.

    ONE of the following surgical locations

    • Lumbar surgery performed below spinal column level L1-L2.
    • Cervical spine surgery.

    Initial Authorization Requirement — Appendix I

    CPT 95940 and HCPCS G0453 require prior authorization when billed with any diagnosis code listed in Appendix I.

    Prior authorization pathway

    • The service is intraoperative neurophysiological testing or monitoring billed with CPT 95940 or HCPCS G0453.
    • The claim includes any Appendix I diagnosis code.
    • Prior authorization is obtained before the service is provided.

    Appendix I diagnosis-code categories

    • Spinal deformity, scoliosis, kyphosis, stenosis, spondylosis, disc, vertebral, cord, or other spinal diagnoses listed in Appendix I, including M40.03, M40.04, M40.05, M40.12-M40.15, M40.202-M40.205, M40.292-M40.295, M40.35-M40.37, M40.45-M40.47, M41.02-M41.08, M41.112-M41.127, M41.22-M41.27, M41.34-M41.35, M41.41-M41.47, M41.52-M41.57, M41.82-M41.87, M43.07, M43.12, M43.16-M43.17, M43.8X1-M43.8X7, M47.011-M47.016, M47.11-M47.16, M47.22, M47.26-M47.27, M47.811-M47.817, M47.896, M48.02-M48.07, M48.41XA-M48.58XA, M48.061-M48.062, M50.01, M50.020-M50.023, M50.03, M50.122-M50.123, M50.20-M50.21, M50.221-M50.223, M50.30-M50.31, M50.322, M50.821-M50.823, M50.921, M51.04-M51.06, M51.16-M51.17, M51.25-M51.27, M51.36, M51.86, M51.9, M53.0, M53.2X1, M54.12, M54.16-M54.17, M54.5, M54.9, M71.38, and related Appendix I codes.

    Medically Necessary Without Prior Authorization — Appendix II

    CPT 95940 and HCPCS G0453 may be considered medically necessary without prior authorization only when billed with a diagnosis code listed in Appendix II and when the applicable coverage and billing requirements are satisfied.

    Appendix II pathway

    • The service is intraoperative neurophysiological testing or monitoring billed with CPT 95940 or HCPCS G0453.
    • The claim includes a diagnosis code listed in Appendix II: Medically necessary without prior authorization.
    • The service is otherwise medically reasonable and necessary for the member's condition and is performed and reported in accordance with this policy and applicable coding rules.

    Appendix II diagnosis categories

    • Intracranial, spinal, neurologic, vascular, neoplastic, seizure, hearing, or other conditions listed in Appendix II, including A18.01, C41.2, C70.0-C70.1, C72.0-C72.9, C73, C79.31-C79.49, D21.0, D32.0-D32.1, D33.0-D33.9, D42.0-D42.9, D43.0-D43.8, D44.3-D44.7, D49.6, G06.1, G40.011-G40.219, G45.0-G45.9, G46.0-G46.2, G50.0-G50.1, G52.9-G54.4, G56.11-G57.03, G60.9, G80.1, G80.4, G80.8-G80.9, G93.5, G95.0, and related Appendix II codes.

    Additional Coverage and Billing Controls

    Coverage is also subject to the following coding, benefit, utilization, and claim-level controls.

    Applicable controls

    • Inclusion or omission of a code from this policy does not guarantee reimbursement or coverage; services remain subject to provider contracts, member benefits, eligibility, medical-necessity review, and utilization audit.
    • All unlisted codes are reviewed at the claim level for medical necessity, correct coding, and pricing. An unlisted code submitted for a non-covered service addressed by this policy is denied as not covered.
    • For potentially covered services, prior authorization is recommended when an unlisted code is used to avoid post-service denial.
    • Applicable company non-covered and prior-authorization lists, coding policies, and benefit provisions also apply.

    Intraoperative Monitoring for Specified Lumbar or Cervical Surgery

    CPT 95940 and HCPCS G0453 will deny as not medically necessary and not covered when performed during the specified lumbar or cervical surgeries and billed with Appendix III diagnosis codes.

    Denial and non-coverage criteria

    • The service is billed with CPT 95940 or HCPCS G0453.

    • Surgical setting

      • Lumbar surgery is performed below spinal column level L1-L2.
      • Cervical spine surgery is performed.
    • The claim includes any diagnosis code listed in Appendix III: Not medically necessary.

    Sensory nerve conduction tests (sNCT; G0255) and nerve conduction studies (CPT 95905, 95907-95912) are outside the scope of this policy. See the applicable Medical Policy Cross References. Surface electromyography (SEMG) is addressed in a separate Medicare Advantage medical policy.

    CPT 95940 and HCPCS G0453 are not covered and will deny as not medically necessary when performed during lumbar surgery below spinal column level L1-L2 or during cervical spine surgery.

    CPT 95941 is not eligible for reimbursement in any setting. Medicare assigns it an invalid status indicator, and it is also not covered under the Company's Intraoperative Neurophysiology Coding Policy (89.0).

    HCPCS S3900 is not valid for Medicare purposes and is not recognized as a valid code for claim submission. Providers must use an alternate available CPT or HCPCS code; an unlisted code may be used only when no specific code is available and remains subject to claim-level review.

    Unlisted codes submitted for services that are non-covered under this policy will be denied as not covered. Unlisted codes for potentially covered services are reviewed for medical necessity, correct coding, and pricing at the claim level; prior authorization is recommended to avoid post-service denial.

    For lumbar surgery below spinal column level L1-L2 or cervical spine surgery, CPT 95940 and HCPCS G0453 are not covered when billed with any Appendix III diagnosis code. Appendix II diagnosis codes provide the separate pathway under which these services may be considered medically necessary without prior authorization, subject to all policy requirements.

    Prior authorization and medical necessity for CPT 95940 and HCPCS G0453 depend on the diagnosis codes billed. Appendix I diagnosis codes require prior authorization; Appendix III diagnosis codes trigger denial as not medically necessary and not covered in the specified surgical circumstances.

    CPT 95937 (neuromuscular junction testing, also known as Train of Four testing) is a routine part of anesthesia care and is not separately billable.

    CPT 95940 and HCPCS G0453 will deny as not medically necessary and not covered when billed with Appendix III diagnosis codes for lumbar surgery below L1-L2 or for cervical spine surgery.

    Coding and Code References

    Intraoperative Monitoring (IOM) in Operating RoomCPT
    95940Continuous intraoperative neurophysiology monitoring in the operating room, one-on-one monitoring requiring personal attendance, each 15 minutes; list separately in addition to code for primary procedure.
    G0453Remote IONM professional services per 15 minutes of focused attention on one patient.
    95707Electroencephalogram (EEG), without video, review of data, technical description by EEG technologist, 2-12 hours; with continuous, real-time monitoring and maintenance.
    95717Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation and report, 2-12 hours of EEG recording; without video.
    95812Electroencephalogram (EEG) extended monitoring; 41-60 minutes.
    95813Electroencephalogram (EEG) extended monitoring; 61-119 minutes.
    95822Electroencephalogram (EEG); recording in coma or sleep only.
    95955Electroencephalogram (EEG) during nonintracranial surgery, such as carotid surgery.
    95957Digital analysis of electroencephalogram (EEG), such as for epileptic spike analysis.
    95925Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs.
    1–10 of 19
    1/2
    Evoked Response TestsCPT
    95925-95927Somatosensory evoked potentials/responses (SEPs/SERs).
    95938Somatosensory evoked potentials/responses (SEPs/SERs).
    92652Brainstem auditory evoked potentials/responses (BAEPs/BAERs).
    92653Brainstem auditory evoked potentials/responses (BAEPs/BAERs).
    95930Visual evoked potentials/responses (VEPs/VERs).
    Invalid and not reimbursableCPTNot Covered
    95941Continuous intraoperative neurophysiology monitoring from outside the operating room, remote or nearby, or monitoring of more than one case while in the operating room.
    Not valid for Medicare claim submissionHCPCSNot Covered
    S3900HCPCS S-code identified as not valid for Medicare purposes and not recognized as a valid claim-submission code.
    Coding restrictions and non-separately billable servicesCPTNot Covered
    95937Neuromuscular Junction Testing.
    95860EMG code; description not provided in the policy window.
    95861EMG code; description not provided in the policy window.
    95863EMG code; description not provided in the policy window.
    95864EMG code; description not provided in the policy window.
    Services outside policy scopeCPT | HCPCS
    G0255Sensory nerve conduction tests (sNCT); not addressed by this policy.
    95905Nerve conduction study; not addressed by this policy.
    95907-95912Nerve conduction studies; not addressed by this policy.
    Intraoperative and associated neurophysiological procedure codesCPT
    95928Central motor evoked potential study (transcranial motor stimulation); upper limbs.
    95929Central motor evoked potential study (transcranial motor stimulation); lower limbs.
    95939Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs.
    95940Continuous intraoperative neurophysiology monitoring in the operating room, one patient.
    92652Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report.
    92653Auditory evoked potentials; neurodiagnostic, with interpretation and report.
    95885Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited.
    95886Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels.
    Additional neurophysiological testing and monitoring codesCPT
    95887Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study.
    95907Nerve conduction studies; 1-2 studies.
    95908Nerve conduction studies; 3-4 studies.
    95909Nerve conduction studies; 5-6 studies.
    95910Nerve conduction studies; 7-8 studies.
    95911Nerve conduction studies; 9-10 studies.
    95912Nerve conduction studies; 11-12 studies.
    95913Nerve conduction studies; 13 or more studies.
    95867Needle electromyography; cranial nerve supplied muscle(s), unilateral.
    95868Needle electromyography; cranial nerve supplied muscles, bilateral.
    1–10 of 20
    1/2
    Appendix I: Prior authorization requiredmixed
    95940Intraoperative neurophysiological testing and monitoring code subject to Appendix I and Appendix II diagnosis-code rules.
    G0453Intraoperative neurophysiological testing and monitoring code subject to Appendix I and Appendix II diagnosis-code rules.
    Appendix II: Medically necessary without prior authorizationmixedCovered
    95940Intraoperative neurophysiological testing and monitoring code that may be considered medically necessary without prior authorization for Appendix II diagnoses.
    G0453Intraoperative neurophysiological testing and monitoring code that may be considered medically necessary without prior authorization for Appendix II diagnoses.
    Appendix I diagnosis codes requiring prior authorizationICD-10
    Appendix I diagnosis codesThe Appendix I diagnosis-code list includes the M40-M54 musculoskeletal/spinal codes, selected M71/M79/M80/M84/M96 codes, P11.5, Q05/Q07/Q27/Q28/Q67/Q85 codes, and S12-S34 traumatic spine and spinal-cord injury codes enumerated in the appendix.
    Appendix II diagnosis codes eligible for consideration without prior authorizationICD-10Covered
    Appendix II diagnosis codesThe Appendix II diagnosis-code list includes neoplasm, neurologic, seizure, cranial-nerve, ear, cerebrovascular, vascular, spinal-cord, and related diagnosis codes enumerated in the appendix, including A18.01, C41.2, C70.0-C73, C79.31-C79.49, D21.0, D32.0-D32.1, D33.0-D33.9, D42.0-D42.9, D43.0-D43.8, D44.3-D44.7, D49.6, G06.1, G40.011-G40.219, G45.0-G46.2, G50.0-G57.03, G80.4-G80.9, G93.5, G95.0, H71.01-H74.43, H83.11-H83.13, H71.91-H71.93, I60.00-I63.9, I65.01-I67.848, I71.01-I71.6, I77.71, I77.74, I77.79, I79.0, and other codes listed in the appendix.
    Not medically necessary and not covered procedure codesmixedNot Covered
    95940Intraoperative neurophysiological testing and monitoring
    G0453Intraoperative neurophysiological testing and monitoring
    Appendix II diagnosis codes associated with denialICD-10Not Covered
    No codes listed
    G0453 Focused Professional Time
    Billing intervalOne G0453 unit represents 15 minutes of remote intraoperative monitoring professional service.
    Minimum focused timeAt least 8 minutes of care must be performed to bill one 15-minute interval.
    Time calculationTotal professional time is the sum of all focused time spent on one patient.
    Restricted Lumbar Surgery Level

    Provider Actions and Billing Guidance

    Prior Authorization

    Diagnosis-Dependent Prior Authorization

    Prior authorization may be required for intraoperative neurophysiological testing and monitoring when CPT 95940 or HCPCS G0453 is billed, depending on the diagnosis code. Review the applicable Appendix I and Appendix II diagnosis pathways before services are rendered.

    • Affected services: CPT 95940 and HCPCS G0453
    Prior Authorization

    Appendix I: Prior Authorization Required

    Obtain prior authorization when CPT 95940 or HCPCS G0453 is billed with any diagnosis listed in Appendix I. The Appendix I diagnosis list controls the requirement, so verify the complete list and submit authorization before the service.

    • CPT 95940 — intraoperative neurophysiological testing and monitoring
    • HCPCS G0453 — remote intraoperative neurophysiological monitoring

    Unsupported block type: info

    Background

    Intraoperative monitoring uses neurophysiological modalities such as EEG, somatosensory evoked potentials, motor evoked potentials, auditory brainstem evoked potentials, and peripheral nerve stimulation during surgery. Medicare coverage criteria govern first; when applicable Medicare statutes, regulations, NCDs, or LCDs do not fully establish coverage criteria, Providence applies its medical policy criteria.

    Definitions

    Evoked Response Tests
    Somatosensory responsesSomatosensory evoked potentials/responses (SEPs/SERs), including CPT 95925-95927 and 95938.
    Brainstem auditory responsesBrainstem auditory evoked potentials/responses (BAEPs/BAERs), including CPT 92652 and 92653.
    Visual responsesVisual evoked potentials/responses (VEPs/VERs), including CPT 95930.
    G0453
    Service settingRemote intraoperative monitoring professional service provided from outside the operating room, remote or nearby.
    Billing intervalReported per 15 minutes, with attention directed exclusively to one patient.
    Policy Summary
    PayerProvidence Health Plan
    PolicyIntraoperative Monitoring
    Policy CodePolicy 296
    Change TypeAnnual reviewno material change
    Effective DateOct 1, 2026
    Last ReviewSep 1, 2026
    Next Review DateSep 1, 2027
    Key ActionObtain prior authorization before service when CPT 95940 or HCPCS G0453 is billed with an Appendix I diagnosis code.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Code ReferencesProvider Actions and Billing GuidanceBackgroundDefinitions
  1. Traumatic spinal, vertebral, cord, or nerve injuries listed in Appendix I, including S12.-, S14.2XXA, S14.3XXA, S22.-, S24.2XXA, S32.-, S34.21XA, S34.22XA, S34.4XXA, S12.000A-S12.691A, S22.009G-S22.089A, and S32.009A-S32.19XA.
  2. Congenital, vascular, neurologic, neoplastic, bone, or other diagnoses listed in Appendix I, including G95.20, G95.9, M80.08XA, M80.88XA, M84.58XA, M84.68XA, M96.2-M96.5, P11.5, Q05.0-Q05.8, Q07.00-Q07.03, Q27.9, Q28.2-Q28.3, Q85.00-Q85.09, and other Appendix I codes.
  3. Cerebrovascular, arterial, aneurysmal, hemorrhagic, ischemic, congenital, or other conditions listed in Appendix II, including I60.00-I60.9, I61.0-I61.9, I62.00-I62.9, I63.00-I63.9, I65.01-I65.23, I65.1, I66.01-I66.23, I66.3, I66.8-I66.9, I67.0-I67.1, I67.5, I67.841, I67.848, I71.01-I71.6, I77.71, I77.74, I77.79, I79.0, and related Appendix II codes.
  4. Spinal and musculoskeletal diagnoses listed in Appendix II, including M47.021, M47.022, M48.02-M48.04, M50.122-M50.223, M50.30, M50.823, M50.921, M51.16-M51.27, M54.16-M54.17, M79.601, M96.0-M96.1, M99.71, and related Appendix II codes.
    5. NCCI procedure-to-procedure edits and CMS medically unlikely edits (MUEs), including daily maximums, apply and take precedence over conflicting policy assumptions.
    Restricted levelBelow spinal column level L1-L2.
    Applicable procedure codesCPT 95940 and HCPCS G0453.
    Coverage consequenceIntraoperative neurophysiological testing and monitoring performed during lumbar surgery below L1-L2 is not medically necessary and is not covered.

    Unsupported block type: documentation

    Unsupported block type: billing_rule

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: billing_rule

    Unsupported block type: billing_rule

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Unsupported block type: denial_risk

    Continuity requirement
    The service does not need to be continuous.
    Focused professional attentionTotal professional time is the sum of all focused time spent on the patient; at least 8 minutes is required to bill a 15-minute interval.
    95940
    Service descriptionContinuous intraoperative neurophysiology monitoring in the operating room.
    Attendance requirementOne-on-one monitoring requiring personal attendance.
    Reporting intervalReported for each 15 minutes.
    Primary procedure reportingListed separately in addition to the code for the primary procedure.
    Intraoperative Neurophysiological Monitoring and Testing
    Monitoring typeContinuous intraoperative neurophysiology monitoring and related neurophysiological testing.
    Motor and auditory modalitiesIncludes motor evoked potentials (MEP) and auditory brainstem evoked potentials (ABR/BAEP).
    Peripheral and muscle modalitiesIncludes peripheral nerve stimulation and electromyography (EMG).
    Additional modalitiesIncludes nerve-conduction studies, cranial-nerve monitoring, visual evoked potentials (VEP), and neuromuscular-junction testing.