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Medical Policy: 02.01.10
Original Effective Date: June 2002
Reviewed: February 2012
Revised: October 2006
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Gait analysis or motion analysis, is a quantitative laboratory assessment of coordinated muscle function, typically requiring a dedicated facility and staff. At its core is the videotaped observation of patient walking. Videos can be observed from several visual planes at slow speed, allowing detection of movements not detectable at normal speed. Joint angles can be measured, and various time-distance variables can be measured including step length, stride length, cadence, and cycle time. Electromyography (EMG), assessed during walking, measures timing and intensity of muscle contractions. This allows determination of whether a certain muscle’s activity is normal, out of phase, continuous, or clonic.
Kinematics is the term used to describe movements of joints and limbs such as angular displacement of joints and angular velocities and accelerations of limb segments. The central element of kinematic assessment is some type of marker system that is used to represent anatomic landmarks, which are then visualized and quantitatively assessed during analysis of videotaped observations. Movement data are compiled by computer from cameras oriented in several planes, and the movement data are processed so that the motion of joints and limbs can be assessed in three dimensions. The range and direction of motion of a particular joint can be isolated from all the other simultaneous motions that are occurring during walking. Graphic plots of individual joint and limb motion as a function of gait phase can be generated.
Kinetics is the term used to describe those factors that cause or control movement. Evaluating kinetics involves the use of principles of physics and biomechanics to explain the kinematics patterns observed and generate analyses that describe the forces generated during normal and abnormal gait analysis.
Gait analysis has been proposed as an aid in surgical planning, primarily for cerebral palsy, and for planning for rehabilitative strategies for a variety of disorders.
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Prior Approval:
Not applicable
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Policy:
Gait analysis may be considered medically necessary for determining any advantages that can be obtained in functionality, performance and safety from the use of a microprocessor controlled prosthetic leg, also known as the C-Leg®, for transfemoral amputees. The assessment must be performed by an independent gait analysis laboratory not associated with any prosthetics supplier.
Gait analysis may be considered medically necessary when performed by an independent gait lab for pre-surgical and post-surgical treatment planning for pediatric cerebral palsy patients.
Gait analysis is considered investigational for any application not listed above.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 96000 Comprehensive computer-based motion analysis by video-taping and 3-D kinematics;
- 96001 Comprehensive computer-based motion analysis by video-taping and 3-D 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
- 96004 Physician review and interpretation 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
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- 2001 TEC Assessment: Gait analysis for pediatric cerebral palsy.
- Peters EJ, Urukalo A, Fleischli JG et al. Reproducibility of gait analysis variables: one-step versus three-step method of data acquisition. J Foot Ankle Surg 2002;41(4):206-12.
- Suda Y, Saitou M, Shibasaki K et al. Gait analysis of patients with neurogenic intermittent claudication. Spine 2002;27(22):2509-13.
- Datta D, Heller B, Howitt J. A comparative evaluation of oxygen consumption and gait pattern in amputees using Intelligent Prostheses and conventionally damped knee swing-phase control. Clin Rehabil. 2005 Jun;19 (4):398-403. Abstract Viewed on Line.
- Miller F, Cardoso Dias R, et al. The effect of rectus EMG patterns on the outcome of rectus femoris transfers. J Pediatr Orthop. 1997 Sep-Oct;17(5):603-7.
- Skaggs DL, Rethlefsen SA, et al. Variability in gait analysis interpretation. J Pediatr Orthop. 2000 Nov-Dec;20(6):759-64.
- Saraph V, Zwick EB, et al. Multilevel surgery in spastic diplegia: evaluation by physical examination and gait analysis in 25 children. J Pediatr Orthop. 2002 Mar-Apr;22(2):150-7.
- Oupuu S, DeLuca P, Davis R, Romness M. Long-term effects of femoral derotation osteotomies: an evaluation using three-dimensional gait analysis. J Pediatr Orthop. 2002 Mar-Apr;22(2):139-45.
- Cook RE, Schneider I, et al. Gait analysis alters decision-making in cerebral palsy. J Pediatr Orthop. 2003 May-Jun;23(3):292-5.
- Murray-Weir M, Root L, et al. Proximal femoral varus rotation osteotomy in cerebral palsy: a prospective gait study. J Pediatr Orthop. 2003 May-Jun;23(3):321-9.
- Dobson F, Morris ME, Baker R, Graham HK. Gait classification in children with cerebral palsy: a systematic review. Gait Posture. 2007 Jan;25(1):140-52. Epub 2006 Feb 21.
- ECRI Institute. Gait Analysis for Management of Neurologic Disorders in Adults. Plymouth Meeting (PA): ECRI Institute; 2008 Sept 3. 12 p. [ECRI hotline response.] Also available: http://www.ecri.org.
- Cimolin V, Galli M, Vimercati SL, et al. Use of the gait deviation index for the assessment of gastrocnemius fascia lengthening in children with cerebral palsy. Res Dev Disabil 2011;32(1):377-81.
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Policy History:
Date Reason Action
April 2011 Annual review Policy renewed
February 2012 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.
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