HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
M-28-035
Topic:
Nerve Conduction Velocity Studies (NCV) and Electromyography (EMG)
Section:
Diagnostic Medical
Effective Date:
September 10, 2018
Issued Date:
September 10, 2018
Last Revision Date:
August 2018
Annual Review:
August 2018
 
 

Electromyography (EMG) is the study and recording of intrinsic electrical properties of skeletal muscles. This is carried out with a needle electrode. Results reflect not only on the integrity of the functioning connection between a nerve and its innervated muscle, but also on the integrity of a muscle itself.

Nerve conduction velocity (NCV) also called nerve conduction study (NCS) is the study of a nerve being stimulated electronically through the skin and underlying tissue to measure nerve conduction time. Results of NCV studies reflect on the integrity and function of the myelin sheath and the axon of the nerve.

EMG and NCV studies are commonly performed in conjunction with each other to confirm a clinical diagnosis of the peripheral nervous system disorders.

Neuromuscular junction testing (repetitive stimulation) 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. Testing may be performed in addition to NCS of the same nerves and/or EMG. Testing is indicated for suspected diseases of the neuromuscular junction (generally associated with progressive motor fatigability) which include myopathy, focal neuropathy, Myasthenia gravis and Lambert Eaton Myasthenic syndrome. Another condition that testing may be indicated for, botulism, is associated with a decrease in the amount of acetylcholine released, and results in weakness.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

EMG may be considered medically necessary for any ONE of the following conditions:
 

  • Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions; or
  • Radiculopathy (cervical, lumbosacral); or
  • Mono/polyneuropathy (metabolic, degenerative, hereditary); or
  • Myopathy (including poly and dermatomyositis, myotonic, and congenital myopathies); or
  • Plexopathy (idiopathic, trauma, infiltration); or
  • Neuromuscular junction disorders (e.g., myasthenia gravis ); or please remove space
  • 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
  • Precise muscle location for injections such as botulinum toxin, phenol, etc.

EMG for any other indication is considered not medically necessary.

 

95860

95861

95863

95864

95865

95867

95868

95869

95870

95872

95885

95886

95887

 




NCV studies may be considered medically necessary for ANY of the following conditions:
 

  • Compressive lesions (neuropathies); or
  • Diagnosis or confirmation of suspected generalized and focal neuropathies/myopathies, (e.g., diabetic, uremic, metabolic, or immune); or
  • Differential diagnosis of symptom-based complaints (e.g., pain in limb, weakness, disturbance in skin sensation or paresthesia) provided the clinical assessment supports the need for a study; or
  • Motor neuron diseases; or
  • Nerve root compression; or
  • Neuromuscular junction disorders (e.g., myasthenia gravis, myasthenic syndrome); or 
  • Plexopathies; or 
  • Traumatic nerve lesions, for diagnosis and prognosis.

 

NCV is considered not medically necessary for any other indications. 

95907

95908

95909

95910

95911

95912

95913

95937

 

 

 

 

 

 




An H-reflex test can be paid separately from any EMG studies and NCV studies listed and should be limited to one unilateral or bilateral study per session per code.

An F-Wave is considered a form of nerve conduction testing. When reported independently, it should be processed according to the number of nerves studied.

Payment higher than the established allowance for an NCV study should not be made if a doctor reports that multiple methods (e.g., surface and needle electrodes) or multiple sites were used, or that an anatomical crossover existed (e.g., a median nerve is stimulated but the ulnar nerve is affected). None of these constitute a circumstance of such an unusual nature as to warrant additional payment.

95907

95908

95909

95910

95911

95912

95913




Electrodiagnostic assessment consisting of EMG and NVC may be considered medically necessary as an adjunct to history, physical exam and imaging studies when the following criteria are met and when performed together and interpreted on the same day for ANY of the following conditions:
 

·         Generalized myopathy, including but not limited to ANY of the following:

o    Polymyositis; or

o    Dermatomyositis; or

o    Myotonic myopathy; or

o    Congenital myopathy; or

o    Muscular dystrophies; or

·         Plexopathies

o    Cervical; or

o    Brachial; or

o    Lumbosacral; or

·         Focal neuropathy, entrapment neuropathy, compressive lesion/syndrome, including but not limited to any of the following:

o    Carpel tunnel; or

o    Cubital tunnel syndrome; or

o    Tarsal tunnel syndrome; or

o    Ulnar nerve entrapment; or

o    Peroneal nerve compression; or

o    Thoracic outlet syndrome; or

o    Other peripheral nerve entrapments; or

·         Generalized neuropathy or confirmed diagnosis including but not limited to any ONE of the following:

o    Metabolic and nutritional (diabetic, uremic, amyloidosis, hypothyroidism, immune, vitamin B12  or thiamine deficiency); or

o    Toxic neuropathy (e.g. vincristine, amiodarone); or

o    Hereditary polyneuropathy (Charcot-Marie tooth Disease); or

o    Demyelinating polyneuropathies;

§  Guillain-Barre' syndrome (acute); or

§  Chronic idiopathic demyelinating polyneuropathy; or

o    Idiopathic peripheral neuropathy; or

o    When used as a diagnostic aid in the evaluation of signs/symptoms suggestive of diabetic or uremic neuropathy; or

o    Alcohol-related neuropathy; or

·         Traumatic peripheral nerve lesion; 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, such as for ANY of the following:

o    Muscle weakness; or

o    Muscle atrophy; or

o    Muscle fasciculation; or

o    Myokymia (involuntary twitching of the eyelid muscles); or

o    Myotonia; or

o    Loss of dexterity; or

o    Spasticity; or

o    Hyperreflexia; or

o    Sensory deficits; or

o    Diplopia; or 

o    Ptosis; or

o    Swallowing dysfunction; or

o    Dysarthria; or

o    Impaired bowel motility; or

·         Motor neuron disease

o    Amyotrophic lateral sclerosis; or

o    Progressive muscular atrophy; or

o    Progressive bulbar palsy; or

o    Pseudobulbar palsy; or

o    Primary lateral sclerosis; or

·         Spine disorder and BOTH of the following:

o    Appropriate imaging studies (e.g., CT scan, MRI, myelogram) confirming nerve root impingement; and any ONE of the following:

§  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.

 

A repeat electrodiagnostic assessment may be considered medically necessary when at least ONE of the following criteria have 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.

 

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

95860

95861

95863

95864

95907

95908

95909

95910

95911

95912

95913

 

 

 




Repetitive Nerve Stimulation (RNS) in the diagnosis of a neuromuscular junction disease may be considered medically necessary for the following conditions:

  • Myopathy; or
  • Motor neuropathy (e.g., ALS); or
  • Botulinum toxicity; or
  • Myasthenia Gravis; or
  • Lambert Eaton myasthenic syndrome; and
  • The presence of ANY of the following symptoms:
    • Diplopia; or
    • Dysphagia; or
    • Fatigue/weakness that progresses with repetitive activity.

RNS for any other indication is considered not medically necessary.

Neuromuscular junction testing (repetitive stimulation) should be processed separately and should be limited to two repetitive stimulations per session.

95937




The following tests are considered experimental/investigational and therefore, non-covered. Scientific evidence does not support the use of these tests.

  • A “surface” EMG (SEMG) which includes a surface paraspinal EMG.
  • Macro EMG.
  • Automated non-invasive electro-diagnostic testing with a computerized hand-held device (e.g., NC-stat®) to stimulate and measure neuromuscular signals.
  • Quantitative sensory testing (QST) which is the assessment of perceptual and/or physiological responses to pain. 

95905

95999

0106T

0107T

0108T

0109T

0110T

S3900

 

 

 

 

 

 




 

Recommended Maximum Number of Electrodiagnostic Studies for Specific Diagnosis

 

Indication

Needle EMG

NCS

Other Studies

 

No. of tests

Motor NCS

±F Wave

Sensory NCS

H-Reflex

RNS Testing

Carpal tunnel Syndrome (Unilateral)

1

3

4

0

0

Carpel tunnel (bilateral)

2

4

6

0

0

Radiculopathy

2

3

2

2

0

Mononeuropathy

1

3

3

2

0

Polyneuropathy/mononeuropathy multiplex

3

4

4

2

0

Myopathy

2

2

2

0

2

Motor neuropathy (e.g. ALS)

4

4

2

0

2

Plexopathy

2

4

6

2

0

Neuromuscular Junction

2

2

2

0

3

Tarsal tunnel syndrome (unilateral)

1

4

4

0

0

Tarsal tunnel syndrome (bilateral)

2

5

6

0

0

Weakness, fatigue, cramps, or twitching (focal)

2

3

4

0

2

Weakness, fatigue, cramps, or twitching (general)

4

4

4

0

2

Pain, numbness, or tingling (focal)

1

3

4

2

0

Pain, numbness, or tingling (general)

2

4

6

2

0

 


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)
Consensus statement:
Using laryngeal electromyography for the diagnosis and treatment of vocal cord paralysis. If prognostic information is required on ultimate vocal fold mobility in a patient 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 a patient with vocal fold immobility that is presumed to be caused by RLN


COVERED DIAGNOSIS CODES FOR PROCEDURES CODES: 95860, 95861, 95863, 95864, 95865, 95869, 95870, 95872, 95885, 95886, 95887, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95937

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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

S84.90XA

S84.90XD

S84.90XS

S84.91XA

S84.91XD

S84.91XS

S84.92XA

S84.92XD

S84.92XS

S84.801A

S84.801D

S84.801S

S84.802A

S84.802D

S84.802S

S84.809A

S84.809D

S84.809S

S94.8X1A

S94.8X2A

S94.8X9A

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


Denial Statements

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.



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.

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.