Clinical UM Guideline
|Subject:||Electromyography and Nerve Conduction Studies|
|Guideline #:||CG-MED-24||Current Effective Date:||01/14/2014|
|Status:||Reviewed||Last Review Date:||11/14/2013|
This Clinical UM guideline addresses the use of electromyography (EMG) and nerve conduction studies (NCS) in the outpatient setting. Needle EMG and NCS typically comprise the electrodiagnostic evaluation of function of the motor neurons, nerve roots, peripheral nerves, neuromuscular junction and skeletal muscles.
Note: For information about other related topics, see:
Needle EMG when performed with NCS at the same time as testing are considered medically necessary for diagnosing neuropathy with sensory loss, weakness and/or muscle atrophy for any of the following indications:
In cases of carpal tunnel syndrome or ulnar neuropathy, the requirement for a period of conservative treatment may be waived if the physical exam demonstrates significant atrophy and/or weakness or sensory loss.
NCS performed without needle EMG at the same time are considered medically necessary in the following clinical situations:
Needle EMG performed without NCS at the same time is considered medically necessary for the evaluation of suspected radiculopathy.
Not Medically Necessary:
Needle EMG performed with NCS are considered not medically necessary when the criteria listed above are not met, including as a screening tool for the general population, in the absence of related symptoms.
NCS performed without needle EMG at the same time is considered not medically necessary except the limited clinical situations listed above.
Needle EMG performed without NCS at the same time is considered not medically necessary when the criteria listed above are not met.
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|95860||Needle electromyography; one extremity with or without related paraspinal areas|
|95861||Needle electromyography; two extremities with or without related paraspinal areas|
|95863||Needle electromyography; three extremities with or without related paraspinal areas|
|95864||Needle electromyography; four extremities with or without related paraspinal areas|
|95867||Needle electromyography; cranial nerve supplied muscle(s), unilateral|
|95868||Needle electromyography; cranial nerve supplied muscle(s), bilateral|
|95869||Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12)|
|95870||Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters|
|95872||Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied|
|95875||Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s) metabolites(s)|
|95885||Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited|
|95886||Needle 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|
|95887||Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study|
|95907||Nerve conduction studies; 1-2 studies|
|95908||Nerve conduction studies; 3-4 studies|
|95909||Nerve conduction studies; 5-6 studies|
|95910||Nerve conduction studies; 7-8 studies|
|95911||Nerve conduction studies; 9-10 studies|
|95912||Nerve conduction studies; 11-12 studies|
|95913||Nerve conduction studies; 13 or more studies|
|95937||Neuromuscular junction testing (repetitive stimulation, paired stimuli); each nerve, any one method|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
In EMG, electrical potentials are detected by a needle electrode inserted directly into a skeletal muscle. This test is useful in the outpatient evaluation of the motor neuron, nerve root, peripheral nerve, neuromuscular junction and the muscle itself. It is helpful in distinguishing between inflammatory and chronic, metabolic or inherited muscle diseases, and in differentiating between acute, recovering, and chronic denervation. While EMG may not necessarily provide a clinical diagnosis, patterns of EMG abnormalities may suggest specific pathologic entities.
NCS performed in the outpatient setting provide information regarding the presence, severity and location of a peripheral neuropathy, mononeuropathy, or disorders affecting the neuromuscular junction. Additional information suggested by NCS includes the functional modality most involved (sensory or motor) and the predominant pattern of pathology, (for example, axonal, demyelinating, or both).
EMG and NCS tests require needle insertion and then repositioning at multiple sites and at anatomically critical areas, in order to assist in clinical diagnosis, prognosis, and clinical management decisions. In NCS, surface electrodes are usually used for both stimulation and recording of the electrical responses. However, needle electrodes are sometimes needed to evaluate a deep nerve, such as the sciatic or the femoral nerve.
EMG and NCS are most effective when preliminary investigation (including history and neurologic examination) is suggestive of a significant probability of pathology. EMG and NCS should be performed and interpreted by individuals with appropriate training and expertise and should be evaluated in the context of the individual clinical scenario.
It is the position of the American Association of Neuromuscular and Electrodiagnostic Medicine, in its Recommended Policy for Electrodiagnostic Medicine (AANEM, 2004), that the selection of the number and type of specific EMG and NCS tests to be performed on an individual is best determined by the testing physician, based on multiple factors, including: the referral diagnosis, presenting symptoms, medical history, findings on prior clinical examination or diagnostic testing, and suspected etiology. The AANEM states further that, except in unique situations, needle EMG and NCS should be performed together in a study design determined by a trained physician, in order that healthcare decisions are based on complete diagnostic information. Some excerpted comments follow:
Nerve conduction studies performed independent of needle EMG may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. When the NCS is used on its own without integrating needle EMG findings, or when an individual relies solely on a review of NCS data, the results can be misleading and important diagnoses may be missed. Moreover, individuals who interpret NCS data without patient interaction or who rely on studies that have delayed interpretation, who have interpretation made off-site, and who interpret results without complementary information obtained from EMG studies are not meeting the standards outlined in the AANEM policy recommendations (AANEM, 2004).
These recommendations from the AANEM were reiterated in 2006 without any changes to the guidance statements. Please see the Table of Maximum Number of Studies per diagnostic category recommended by the AANEM, as reasonably necessary for a physician to arrive at a diagnosis in 90% of individuals with that final diagnosis, which is available at: http://www.aanem.org/getmedia/b0af02d9-943c-4f78-aa91-91da3f582b49/Recommended_Policy_EDX_Medicine_07152010.pdf.aspx. (AANEM, 2004)
In another AANEM document, the Model Policy for Needle Electromyography (NEMG) and Nerve Conduction Studies (NCS) issued in 2010, the following was noted:
The AANEM does not support screening testing, monitoring disease intensity, or monitoring of treatment efficacy for polyneuropathy of diabetes or polyneuropathy of end stage renal disease (ESRD). NEMG is also not recommended for any of the following:
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:Index
Electromyography, Nerve Conduction Studies
Nerve Conduction Studies, Electromyography
Nerve Conduction Velocity Studies
The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.
|Reviewed||11/14/2013||Medical Policy & Technology Assessment Committee (MPTAC) review. No change to criteria. The Discussion section and References were updated.|
|Reviewed||11/08/2012||MPTAC review. No change to criteria. Updated Reference section. Updated Coding section with 01/01/2013 CPT changes.|
|Revised||11/17/2011||MPTAC review. The medically necessary criteria for testing were revised to clarify that needle EMG is to be performed with NCS, in order to meet medical necessity. New statements were added to address the medical necessity criteria for performance of NCS without EMG and for doing EMG without NCS. The Appendix was removed. The Discussion and References were updated. Updated Coding section with 01/01/2012 CPT changes.|
|Reviewed||02/17/2011||MPTAC review. No change to criteria. References were updated.|
|Reviewed||02/25/2010||MPTAC review. No change to criteria. Information in the Description and Discussion sections was clarified to indicate that this document addresses outpatient use of these testing modalities. References and coding were updated.|
|Reviewed||02/26/2009||MPTAC review. The formatting of the medical necessity criteria was updated with no change to the actual criteria. Removed the section on Place of Service/Duration. References were updated.|
|Reviewed||02/21/2008||MPTAC review. No change to medical necessity criteria. References were updated.|
|Revised||03/08/2007||MPTAC review. Revised guideline statement to delete reference to unknown etiology under peripheral neuropathy indications. Added "ors" for clarification under medically necessary indications. Discussion section was also updated with some clarifying language about the AANEM Recommended Policy for Electrodiagnostic Medicine.|
|Reviewed||12/07/2006||MPTAC review. No change to guideline criteria. References and coding were updated.|
|Revised||12/01/2005||MPTAC review. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint.|
Last Review Date
|WellPoint Health Networks, Inc.|
|Clinical Guideline||Electromyography and Nerve Conduction Study (EMG/NCS)|