Clinical UM Guideline
|Subject:||Electromyography and Nerve Conduction Studies|
|Guideline #:||CG-MED-24||Current Effective Date:||06/28/2016|
|Status:||Revised||Last Review Date:||05/05/2016|
This document 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. This document also addresses neuromuscular junction testing regardless of place of service.
Note: For information about other related topics, see:
Not Medically Necessary:
Needle EMG performed with NCS at the same time of testing 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 of testing is considered not medically necessary except the limited clinical indications listed above.
Needle EMG performed without NCS at the same time of testing is considered not medically necessary when the criteria listed above are not met.
Testing for neuromuscular junction diseases with needle EMG or NCS is considered not medically necessary when the criteria above are not met, and for all other indications.
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|
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 (AANEM), in its Recommended Policy for Electrodiagnostic Medicine (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. In the 2015 position statement Proper Performance and Interpretation of Electrodiagnostic Studies, AANEM states that except for 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:
When NCSs are performed without needle EMG, the additional and complementary information provided by the needle EMG results (except in limited circumstances) is not available. Without the information provided by the needle EMG examination, valuable data that may be essential to establishing an accurate diagnosis is missing. ….Additionally, patients typically need to have both NCSs and needle EMG to ensure that an underlying medical condition is not being missed.
In another AANEM document, the Model Policy for Needle Electromyography and Nerve Conduction Studies, updated in 2016, the following was noted:
The necessity and reasonableness of the following uses of needle EMG studies have not been established:
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
|Websites for Additional Information|
Electromyography, Nerve Conduction Studies
Nerve Conduction Studies, Electromyography
Nerve Conduction Velocity (NCV) 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.
|Revised||05/05/2016||Medical Policy & Technology Assessment Committee (MPTAC) review. Minor change to clinical indications, move the Note statement and added asterisks. Updated the Discussion and References sections. Added a Websites for Additional Information section. Removed ICD-9 codes from Coding section.|
|Revised||05/07/2015||MPTAC review. A medically necessary statement was added to the Clinical Indications section for needle EMG when performed with NCS at the same time for neuromuscular junction diseases for clarification. A not medically necessary statement was added for neuromuscular junction testing with needle EMG or NCS when criteria are not met and for all other indications. References were updated.|
|Reviewed||11/13/2014||MPTAC review. The Discussion section and References were updated.|
|Reviewed||11/14/2013||MPTAC review. The Discussion section and References were updated.|
|Reviewed||11/08/2012||MPTAC review. 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. References were updated.|
|Reviewed||02/25/2010||MPTAC review. 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. 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. References and coding were updated.|
|Revised||12/01/2005||MPTAC review. Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint.|
|Pre-Merger Organizations||Last Review Date||Document Number||Title|
|Anthem, Inc.||No document|
|Anthem BCBS||No document|
|WellPoint Health Networks, Inc.||07/14/2005||Clinical Guideline||Electromyography and Nerve Conduction Study (EMG/NCS)|