Mountain State Medical Policy Bulletin
Section: Diagnostic Medical
Number: M-30
Topic: Gait Analysis and Electrodynogram
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 08/2005

General Policy Guidelines

Indications and Limitations of Coverage

Motion analysis (96000-96004), with or without electrodynogram, is not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied services.

Electrodynograms billed independently are also not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.  Use procedure code 95999 to report an electrodynogram.

Description

An electrodynogram is a computerized, diagnostic device that quantitatively measures the weight bearing forces exerted by the feet and legs. The electrodynogram is one of many devices used in motion analysis (96000-96004). Gait and motion analysis are diagnostic services.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

959999600096001960029600396004

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Motion analysis (96000-96004) is considered eligible.

Also refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.