HIGHMARK COMMERCIAL MEDICAL POLICY - DELAWARE

 
 
Medical Policy:
M-28-015
Topic:
Nerve Conduction Studies and Electromyography
Section:
Diagnostic Medical
Effective Date:
November 18, 2019
Issued Date:
November 18, 2019
Last Revision Date:
October 2019
Annual Review:
October 2019
 
 

Electromyography (EMG) and nerve conduction studies (NCS), also collectively known as an electrodiagnostic assessment, evaluate the electrical functioning of muscles and peripheral nerves. These tests are diagnostic aids for the evaluation of disorders of the peripheral nervous system by identifying, localizing, and characterizing electrical abnormalities in the skeletal muscles and peripheral nerves.

In addition to NCS and/or EMG, neuromuscular junction testing (repetitive nerve stimulation) may be performed and involves recording muscle responses to a series of nerve stimuli applied at differing rates, both before and after exercise or transmission of high-frequency stimuli.

Policy Position

Electrodiagnostic assessment, consisting of EMG, NCS, and related measures, may be considered medically necessary as an adjunct to history, physical exam, and imaging studies when the following criteria are met:

  • Signs and symptoms of peripheral neuropathy and/or myopathy are present; and
  • Definitive diagnosis cannot be made by physical exam and imaging studies alone; and
  • Work-up for ONE OR MORE of the following categories of disease is indicated (see list below):
    • Motor neuron diseases; or
    • Nerve root compression; or
    • Neuromuscular junction disorders; or
    • Neuropathies, compressive; or
    • Neuropathies/myopathies, generalized and focal; or
    • Plexopathies; or
    • Traumatic nerve injuries.

A repeat electrodiagnostic assessment may be considered medically necessary when at least one of the following criteria has been met:

  • Development of new symptoms or signs suggesting a second diagnosis in a patient who has received an initial diagnosis; or
  • Interim progression of disease following an initial test that was inconclusive, such that a repeat test is likely to elicit additional findings; or
  • Unexpected change(s) in the course of disease or response to treatment, suggesting that the initial diagnosis may be incorrect and that reexamination is indicated; or
  • Rapidly evolving disease in which initial electrodiagnostic testing is normal and where repeat testing might show abnormalities that will affect treatment decisions, (e.g., Guillain-Barre Syndrome); or
  • In diseases with fluctuating courses to monitor disease progress and response to therapeutic interventions (e.g. polymyositis and myasthenia gravis); or
  • Repeat evaluations after injury to monitor recovery, to help establish prognosis, and to determine the need for possible further interventions.

Electrodiagnostic assessment consisting of EMG and NCS for any other indications is considered not medically necessary.

95860

95861

95863

95864

95865

95866

95867

95868

95869

95870

95872

95885

95886

95887

95905

95907

95908

95909

95910

95911

95912

95913

95937

 

 

 

 

 


Electrodiagnostic assessment, consisting of EMG, NCS, and related measures, is considered experimental/investigational and therefore non-covered because the safety and and/or effectiveness of this service cannot be established by the available published peer-reviewed literature:

 

  • Screening of asymptomatic individuals
  • These tests may include, but are not limited to:
    • A “surface” EMG (SEMG) which includes a surface paraspinal EMG.
    • Macro EMG.
    • Quantitative sensory testing (QST) which is the assessment of perceptual and/or physiological responses to pain.

95999

0106T

0107T

0108T

0109T

0110T

S3900


The following list gives specific diagnoses, according to categories of testing listed in the policy statement above for which EMG and NCS generally provide useful information in confirming or excluding the diagnosis than provided by clinical examination and imaging alone. The diagnosis list is not exhaustive as there may also be less common disorders for which EMG/NCS provide useful diagnostic information:

  • Motor neuron diseases:
    • Amyotrophic lateral sclerosis; or
    • Primary lateral sclerosis; or
    • Progressive bulbar palsy; or
    • Progressive muscular atrophy; or
    • Pseudobulbar palsy; or
  • Myopathies, generalized:
    • Congenital myopathy; or
    • Dermatomyositis; or
    • Muscular dystrophies; or
    • Myotonic myopathy; or
    • Polymyositis; or
  • Nerve root compression (when physical exam and magnetic resonance imaging are inconclusive):
    • Cervical nerve root compression; or
    • Lumbosacral nerve root compression; or
    • Thoracic nerve root compression; or
  • Nerve root, peripheral nerve, muscle, or neuromuscular junction involvement with symptom- based presentation and pre-test evaluations are inconclusive and clinical assessment supports the need for the study for ANY of the following: 
    • Diplopia; or
    • Dysarthria; or
    • Impaired bowel motility; or
    • Fatigue/weakness that progresses with repetitive activity; or
    • Hyperreflexia; or
    • Impaired bowel motility; or
    • Loss of dexterity; or
    • Muscle atrophy; or
    • Muscle fasciculation; or
    • Muscle weakness; or
    • Myokymia (involuntary twitching of the eyelid muscles); or
    • Myotonia; or
    • Ptosis; or
    • Sensory deficits; or
    • Spasticity; or
    • Swallowing dysfunction; or
  • Neuromuscular junction disorders:
    • Botulinum toxicity: or
    • Lambert-Eaton myasthenic syndrome; or
    • Myasthenia gravis; or
    • Myasthenic Syndrome; or
  • Neuropathies, Compressive
    • Carpal tunnel syndrome; or
    • Cubital tunnel syndrome; or
    • Other peripheral nerve entrapments; or
    • Peroneal nerve compression; or
    • Recurrent laryngeal neuropathy (RLN), (unilateral or bilateral vocal cord fold paralysis) that is greater than four (4) weeks but less than six (6) months in duration; or
    • Tarsal tunnel syndrome; or
    • Thoracic outlet syndrome; or
    • Ulnar nerve entrapment; or
  • Plexopathies:
    • Brachial plexopathy; or
    • Cervical plexopathy; or
    • Lumbosacral plexopathy; or
  • Polyneuropathies, generalized and focal:
    • Alcohol-related neuropathy; or
    • Diabetic neuropathy; or
    • Demyelinating polyneuropathies:
      • Guillain-Barré syndrome (acute); or
      • Chronic idiopathic demyelinating polyneuropathy; or
    • Hereditary neuropathies:
      • Charcot-Marie-tooth disease; or
      • Other hereditary neuropathies; or
    • Idiopathic peripheral neuropathy; or
    • Metabolic and nutritional (amyloidosis, hypothyroidism, immune, vitamin B12, or thiamine deficiency); or
    • Toxic neuropathy (e.g. vincristine, amiodarone); or
    • Uremic neuropathy; or
  • Precise muscle location for injections such as botulinum toxin, phenol, etc.; or
  • Radiculopathy
    • Cervical; or
    • Lumbosacral; or
    • Thoracic; or
  • Spine disorders
    • To differentiate radiculopathy from other neuropathies or non-neuropathic processes; or
    • To establish whether imaging findings are responsible for reported pain; or
    • To reconcile when pattern of pain, sensory impairment, or weakness does not match imaging findings; or
    • To document degree of axonal nerve damage in an individual with weakness; or
  • Traumatic nerve injuries.

The following table represents the recommended maximum number of electrodiagnostic studies from the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) position statement (2017).  These estimates do not represent absolute maximums for all patients; they are defined by AANEM as being sufficient to make a diagnosis in at least 90% of patients with that particular diagnosis. Therefore, there may be a small percentage of cases that require a greater number of tests than specified.

Recommended Maximum Number of Electrodiagnostic Studies

 

Needle EMG

Nerve Conduction Studies

Other Electrodiagnostic Studies

Indication

Number of Services (Tests)

Motor NCS with and/or without F-wave

Sensory NCS

H-Reflex

Neuromuscular Junction Testing (Repetitive Stimulation)

Carpal Tunnel (unilateral)

1

3

4

-

-

Carpal Tunnel (bilateral)

2

4

6

-

-

Radiculopathy

2

3

2

2

-

Mononeuropathy

1

3

3

2

-

Polyneuropathy/Mononeuropathy Multiplex

3

4

4

2

-

Myopathy

2

2

2

-

2

Motor Neuronopathy (e.g. ALS)

4

4

2

-

2

Plexopathy

2

4

6

2

-

Neuromuscular Junction

2

2

2

-

3

Tarsal Tunnel Syndrome (unilateral)

1

4

4

-

-

Tarsal Tunnel Syndrome (bilateral)

2

5

6

-

-

Weakness, Fatigue, Cramps, or Twitching (focal)

2

3

4

-

2

Weakness, Fatigue, Cramps, or Twitching (general)

4

4

4

-

2

Pain, Numbness, or Tingling (unilateral)

1

3

4

2

-

Pain, Numbness, or Tingling (bilateral)

2

4

6

2

-
Related Policies

Refer to Medical Policy M-13, Intraoperative Neurophysiologic Monitoring (Sensory-Evoked Potentials, Motor-Evoked Potentials, EEG Monitoring), for additional information.

Refer to Medical Policy I-11, Botulinum Toxin (Chemodenervation), for additional information.


Professional Statements and Societal Positions Guidelines

The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis. If prognostic information is required on ultimate vocal fold mobility in an individual with vocal fold paralysis that is greater than four (4) weeks and less than six (6) months in duration, LEMG should be performed. LEMG may be performed to clarify treatment decisions in an individual with vocal fold immobility that is presumed to be caused by RLN (2016).

NCS performed independent of needle EMG studies may only provide a portion of the information needed to diagnose muscle, nerve root, and most nerve disorders. For this reason, it is the position of the AANEM that, except in unique situations, NCSs and needle EMG should be performed together in a study design determined by a trained neuromuscular physician. There are common diagnoses that depend on performing a needle EMG and combining the needle EMG data with the NCS data. Needle EMG studies are a necessary part of the evaluation in the diagnosis of myopathy, radiculopathy, plexopathy, disorders of the motor neuron, peripheral neuropathies and most disorders of the individual peripheral motor nerves. 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 often be misleading, and important diagnoses will likely be missed. Patients may thus be subjected to incorrect, unnecessary, and potentially harmful treatment interventions (2017).

AANEM policy statement on electrodiagnosis for distal symmetric polyneuropathy (2018): Electrodiagnostic (EDX) studies are often very helpful in the diagnosis and management of patients who have or are suspected to have Distal Symmetric Polyneuropathy (DSP). However, EDX studies may not be appropriate in every situation. There are five common scenarios in which EDX studies are likely to be beneficial: (1) determining primary and alternative diagnoses; (2) determining severity, duration and prognosis of disease; (3) evaluating risk of associated problems; (4) determining the effect of medications; and (5) evaluating the effect of toxic exposures.


COVERED DIAGNOSIS CODES FOR PROCEDURES CODES: 95860, 95861, 95863, 95864, 95865, 95869, 95870, 95872, 95885, 95886, 95887, 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913

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S32.049K

S32.049S

S32.059A

S32.059B

S32.059D

S32.059G

S32.059K

S32.059S

S32.10XA

S32.10XB

S32.10XD

S32.10XG

S32.10XK

S32.10XS

S32.2XXA

S32.2XXB

S32.2XXG

S32.2XXK

S32.2XXS

S34.02XA

S34.131A

S34.131D

S34.131S

S34.132A

S34.132D

S34.132S

S34.139A

S34.139D

S34.139S

S34.21XA

S34.21XD

S34.21XS

S34.22XA

S34.22XD

S34.22XS

S34.3XXA

S34.3XXD

S34.3XXS

S34.4XXA

S34.4XXD

S34.4XXS

S34.5XXA

S34.5XXD

S34.5XXS

S34.6XXA

S34.6XXD

S34.6XXS

S34.8XXA

S34.8XXD

S34.8XXS

S34.9XXA

S34.9XXD

S34.9XXS

S44.00XA

S44.00XD

S44.00XS

S44.01XA

S44.01XD

S44.01XS

S44.02XA

S44.02XD

S44.02XS

S44.10XA

S44.10XD

S44.10XS

S44.11XA

S44.11XD

S44.11XS

S44.12XA

S44.12XD

S44.12XS

S44.20XA

S44.20XD

S44.20XS

S44.21XA

S44.21XD

S44.21XS

S44.22XA

S44.22XD

S44.22XS

S44.30XA

S44.30XD

S44.30XS

S44.31XA

S44.31XD

S44.31XS

S44.32XA

S44.32XD

S44.32XS

S44.40XA

S44.40XD

S44.40XS

S44.41XA

S44.41XD

S44.41XS

S44.42XA

S44.42XD

S44.42XS

S44.50XA

S44.50XD

S44.50XS

S44.51XA

S44.51XD

S44.51XS

S44.52XA

S44.52XD

S44.52XS

S44.8X1A

S44.8X1D

S44.8X1S

S44.8X2A

S44.8X2D

S44.8X2S

S44.8X9A

S44.8X9D

S44.8X9S

S44.90XA

S44.90XD

S44.90XS

S44.91XA

S44.91XD

S44.91XS

S44.92XA

S44.92XD

S44.92XS

S54.00XA

S54.00XD

S54.00XS

S54.01XA

S54.01XD

S54.01XS

S54.02XA

S54.02XD

S54.02XS

S54.10XA

S54.10XD

S54.10XS

S54.11XA

S54.11XD

S54.11XS

S54.12XA

S54.12XD

S54.12XS

S54.20XA

S54.20XD

S54.20XS

S54.21XA

S54.21XD

S54.21XS

S54.22XA

S54.22XD

S54.22XS

S54.30XA

S54.30XD

S54.30XS

S54.31XA

S54.31XD

S54.31XS

S54.32XA

S54.32XD

S54.32XS

S54.8X1A

S54.8X1D

S54.8X1S

S54.8X2A

S54.8X2D

S54.8X2S

S54.8X9A

S54.8X9D

S54.8X9S

S54.90XA

S54.90XD

S54.90XS

S54.91XA

S54.91XD

S54.91XS

S54.92XA

S54.92XD

S54.92XS

S64.00XA

S64.00XD

S64.00XS

S64.01XA

S64.01XD

S64.01XS

S64.02XA

S64.02XD

S64.02XS

S64.10XA

S64.10XD

S64.10XS

S64.11XA

S64.11XD

S64.11XS

S64.12XA

S64.12XD

S64.20XA

S64.20XD

S64.20XS

S64.21XA

S64.21XD

S64.21XS

S64.22XA

S64.22XD

S64.22XS

S64.30XA

S64.30XD

S64.30XS

S64.31XA

S64.31XD

S64.31XS

S64.32XA

S64.32XD

S64.32XS

S64.40XA

S64.40XD

S64.40XS

S64.490A

S64.490D

S64.490S

S64.491A

S64.491D

S64.491S

S64.492A

S64.492D

S64.492S

S64.493A

S64.493D

S64.493S

S64.494A

S64.494D

S64.494S

S64.495A

S64.495D

S64.495S

S64.496A

S64.496D

S64.496S

S64.497A

S64.497D

S64.497S

S64.498A

S64.498D

S64.498S

S64.8X1A

S64.8X1D

S64.8X1S

S64.8X2A

S64.8X2D

S64.8X2S

S64.8X9A

S64.8X9D

S64.8X9S

S64.90XD

S64.90XS

S64.91XA

S64.91XD

S64.91XS

S64.92XA

S64.92XD

S64.92XS

S74.00XA

S74.00XD

S74.00XS

S74.01XA

S74.01XD

S74.01XS

S74.02XA

S74.02XD

S74.02XS

S74.10XA

S74.10XD

S74.10XS

S74.11XA

S74.11XD

S74.11XS

S74.12XA

S74.12XD

S74.12XS

S74.20XA

S74.20XD

S74.20XS

S74.21XA

S74.21XD

S74.21XS

S74.22XA

S74.22XD

S74.22XS

S74.8X1A

S74.8X1D

S74.8X1S

S74.8X2A

S74.8X2D

S74.8X2S

S74.8X9A

S74.8X9D

S74.8X9S

S74.90XA

S74.90XD

S74.90XS

S74.91XA

S74.91XD

S74.91XS

S74.92XA

S74.92XD

S74.92XS

S84.00XA

S84.00XD

S84.00XS

S84.01XA

S84.01XD

S84.01XS

S84.02XA

S84.02XD

S84.02XS

S84.10XA

S84.10XD

S84.10XS

S84.11XA

S84.11XD

S84.11XS

S84.12XA

S84.12XD

S84.12XS

S84.20XA

S84.20XD

S84.20XS

S84.21XA

S84.21XD

S84.21XS

S84.22XA

S84.22XD

S84.22XS

S84.801A

S84.801D

S84.801S

S84.802A

S84.802D

S84.802S

S84.809A

S84.809D

S84.809S

S84.90XA

S84.90XD

S84.90XS

S84.91XA

S84.91XD

S84.91XS

S84.92XA

S84.92XD

S84.92XS

S94.00XA

S94.00XD

S94.00XS

S94.01XA

S94.01XD

S94.01XS

S94.02XA

S94.02XD

S94.02XS

S94.10XA

S94.10XD

S94.10XS

S94.11XA

S94.11XD

S94.11XS

S94.12XA

S94.12XD

S94.12XS

S94.20XA

S94.20XD

S94.20XS

S94.21XA

S94.21XD

S94.21XS

S94.22XA

S94.22XD

S94.22XS

S94.30XA

S94.30XD

S94.30XS

S94.31XA

S94.31XD

S94.31XS

S94.32XA

S94.32XD

S94.32XS

S94.8X1A

S94.8X1D

S94.8X1S

S94.8X2A

S94.8X2D

S94.8X2S

S94.8X9A

S94.8X9D

S94.8X9S

S94.90XA

S94.90XD

S94.90XS

S94.91XA

S94.91XD

S94.91XS

S94.92XA

S94.92XD

S94.92XS

 

 

 

 


Place of Service: Inpatient/Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

EMG/NCS is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

The policy position applies to all commercial lines of business



Links





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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state.


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

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. 




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
    • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.