Medicare Advantage

Medical Policy

Notification

Electromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic Studies

Notification Issued Date:

Title:

Electromyography (EMG) Studies, Nerve Conduction Studies (NCS), and Related Electrodiagnostic Studies

Policy #:

MA07.050l

Policy

MEDICALLY NECESSARY

INDEX OF MEDICALLY NECESSARY INDICATIONS

This policy addresses numerous medically necessary indications for electrodiagnostic studies. Please see below for the specific medical necessity criteria. (NOTE: Not Medically Necessary and Not Covered sections below must also be reviewed).

Electrodiagnostic (EDX) Studies

Needle Electromyography (NEMG) and Nerve Conduction Studies (NCS)

EMG of anal and urethral sphincter

NEMG for precise muscle location for intramuscular agents

NCS performed without NEMG

Neuromuscular junction testing

Somatosensory evoked potentials (SEPs)

NEEDLE ELECTROMYOGRAPHY (NEMG) AND NERVE CONDUCTION STUDIES (NCS)

Needle electromyography (NEMG) and nerve conduction studies (NCS), which provides amplitude, latency, configuration, and conduction velocity data, are considered medically necessary when they are performed and interpreted at the same time, on site, and in real time for any of the following circumstances:

Plexopathy (including idiopathic, traumatic, inflammatory, or infiltrative, radiation-induced, brachial plexopathies (e.g. neuralgic amyotrophy, thoracic outlet syndrome), and lumbosacral plexopathies (e.g. diabetic, non-diabetic lumbosacral radiculoplexus neuropathy
Focal neuropathies (e.g., entrapment neuropathies or compressive lesions/syndromes such as carpal tunnel syndrome, ulnar neuropathy, tarsal tunnel syndrome, femoral neuropathy, saphenous neuropathy, lateral femoral cutaneous neuropathy, peroneal (fibular) neuropathy, tibial neuropathies, sciatic neuropathy)
Generalized neuropathies such as metabolic (e.g., diabetic, uremic), toxic, hereditary or immune-mediated
Motor neuron disease (e.g., amyotrophic lateral sclerosis [ALS] or Lou Gehrig's disease)
Myopathy - including inflammatory myopathies such as polymyositis and dermatomyositis, congenital myopathies, congenital and hereditary dystrophic and nondystrophic myopathies, including myotonic muscular dystrophy, acquired myopathies (drug induced myopathy associated with statins, thyroid related), metabolic myopathies (e.g., McArdle disease) (including polymyositis and dermatomyositis; myotonic and congenital myopathies)
Myotonic disorders (e.g., drug induced myotonia)
Neuromuscular junction disorders (e.g., myasthenia gravis, Lambert-Eaton myasthenic syndrome, botulism)
Polyneuropathies
Radiculopathy – cervical, thoracic, or lumbosacral
Spinal cord disorders (i.e., myelopathy)
Symptom-based presentations such as “pain in limb", weakness, cramping/twitching, disturbance of skin sensation or “paresthesia" when appropriate pre-test evaluations are inconclusive, and the clinical assessment unequivocally supports the need for the study
Traumatic nerve lesions, for diagnosis and prognosis
Mononeuropathy and polyneuropathy (metabolic, degenerative, hereditary)

EMG studies of the urethral or anal sphincter are considered medically necessary and, therefore, covered for the following conditions:

Constipation
Fecal incontinence
Urinary incontinence
Bladder outlet obstruction (a blockage at the base of the bladder that reduces or prevents the flow of urine into the urethra)
Neurogenic conditions of the anal or urethral sphincter resulting from disorders such as multiple sclerosis, spinal cord injury, paralysis, or motor neuron disease
Diabetic autonomic (poly)neuropathy

Precise muscle location with NEMG for injection of intramuscular agents (e.g., botulinum toxin, phenol or other substances for nerve blocking or chemodenervation) is considered medically necessary for the following conditions:

Paralysis (e.g., monoplegia, hemiplegia, diplegia, quadriplegia, and paraplegia)
Strabismus (e.g., esotropia, extropia, and cyclotropia)
Nerve palsy - oculomotor, trochlear, abducent
Facial spasm
Chronic migraine
Hyperhydrosis
Bladder and anal disorders or incontinence

NEMG of the larynx is considered medically necessary for the following conditions:

Paralysis of vocal cords and larynx
Dysphagia
Dysphonia

Single Fiber Electromyography (SFEMG) is considered medically necessary for the following conditions:

Ocular myasthenia
Myasthenia gravis
Myasthenic syndrome (e.g., Lambert-Eaton myasthenic syndrome)

NCSs when performed without NEMG are considered medically necessary for the following situations:

Individuals treated with anticoagulants such as warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), edoxaban (Lixiana), clopidogrel (Plavix), ticagrelor (Brilinta), ticlopidine (Ticlid), prasugrel (Effient), varapaxar (Zontivity), dipyridamole, cilostazol (Pletal)
Individuals with significant lymphedema in the affected extremity
Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome

Neuromuscular junction testing (NJT) is considered medically necessary for the following conditions:

Neuromuscular junction disorders (e.g., myasthenia gravis, Lambert-Eaton myasthenic syndrome, botulism)
Carnitine deficiency
Glycogen storage diseases (e.g., Pompe's disease, Forbes-Cori disease , McArdle's disease)
Myopathy (including myotosis)
Myalgia
Muscle weakness and atrophy
Dysphagia

Somatosensory evoked potentials (SEPs) and central motor evoked potentials (CMEPs) are considered medically necessary for the following conditions:

Spinal cord trauma
Degenerative, non-traumatic spinal cord lesions (e.g., cervical spondylosis with myelopathy)
Multiple sclerosis
Spinocerebellar degeneration
Myoclonus
Coma
Intraoperative monitoring
Subacute combined degeneration
Other diseases of myelin (e.g., adrenoleukodystrophy, adrenomyeloneuropathy, metachromatic leukodystrophy, and Pelizaeus-Merzbacher disease)
Syringomyelia
Hereditary spastic paraplegia

Please refer to attachment A of this policy for American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines for recommended maximum number of EMG.

NOT MEDICALLY NECESSARY
Needle EMG or NCS for any other indication is considered not medically necessary and, therefore, not covered. Examples of indications include, but are not limited to:

Delayed and incomplete interpretation of the NEMG study; NEMG study must be performed and interpreted with the NCS on site and in real time (excluding conditions listed above)
Non-invasive EDX studies using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysis
Testing for polyneuropathy of diabetes in individuals without clinical deficits or for the sole purpose of monitoring disease intensity or treatment efficacy
NCSs accomplished with discriminatory devices that use fixed anatomic templates and computer-generated reports used as an adjunct to physical examination routinely on all individuals
Physiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopes
NCS or EMG for muscle pain without the presence of other abnormalities on examination or in laboratory testing
NEMG for the following situations:

Definitive diagnosis based on paraspinal NEMG in areas with scar from past surgeries (e.g., previous laminectomies)
Surface electromyography (SEMG)
Macroelectromyography (macro-EMG)
NEMG for isolated neck or back pain after a motor vehicle accident
Exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions
Pattern-setting limited limb muscle examinations, without paraspinal muscle testing for the diagnosis of radiculopathies
Premature needle EMG testing after trauma when EMG changes have not taken place
Multiple uses of needle EMG in the same individual at the same location of the same limb for the purpose of optimizing botulinum toxin injections have not been supported.

NOT COVERED

The following services are not covered by the Company because these services are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration:

Needle oculoelectromyography
Needle electromyography of hemidiaphragm
Motor and/or sensory nerve conduction using preconfigured electrode arrays, with or without F-wave study
Blink reflex test
Quantitative Sensory Testing (QST) (e.g., hot-cold, touch, vibration)
Sensory Nerve Conduction Threshold (sNCT) Testing including Pain Perception Threshold (PPT), Pain Tolerance Threshold (PTT), and Voltage-Actuated Sensory Nerve Conduction Threshold (VsNCT)

PROFESSIONAL AND TECHNICAL REIMBURSEMENT

Only physicians (MD/DO) are eligible to receive reimbursement for the professional component of EMG and/or NCS. Physicians may also receive reimbursement for the technical component if they performed that service.
Non-physician professional providers (e.g., physical therapists) are only eligible to receive reimbursement for the technical component of EMG and/or NCS.

STATE OF NEW JERSEY

In the state of New Jersey, as defined by the scope of practice regulations, only a physician may perform needle EMG studies.

REQUIRED DOCUMENTATION
Documentation of the performing professional provider's qualifications must be made available to the Company upon request.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

BILLING GUIDELINES

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

CPT Procedure codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913 would not be appropriate to report for nerve conduction studies (NCS) using preconfigured electrode array(s).

MINIMUM STANDARDS FOR NEEDLE ELECTROMYOGRAPHY (EMG) AND NERVE CONDUCTION STUDIES (NCS)

The Company has adopted the minimum standards for electrodiagnostic studies as defined by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Minimum standards include the following:

Testing should be performed using equipment that assesses all parameters of the recorded signals.
- Studies that are performed with devices designed only for screening, rather than diagnosing, are not eligible under this policy.
The number of tests performed should be the minimum that are necessary to establish an accurate diagnosis, which may include evaluation of one or more nerves that have normal test results for comparative purposes.

Please refer to Attachment A of this policy for the AANEM recommendations regarding the maximum number of studies that should be performed for each condition, as well as examples of clinical situations where additional testing may be appropriate. These recommendations should not apply if the individual requires evaluation by more than one consultant (.ie., a second opinion or an expert opinion at a tertiary care center) in a given year or if the individual requires evaluation for a second diagnosis in a given year.

CLINICAL SPECIALIZATION PROGRAMS

Eligible professional providers performing a needle EMG should have sufficient knowledge and experience in needle EMG. Competency to perform needle EMG can be demonstrated through training from a clinical specialization program. Candidates are able to demonstrate their level of competence from a certification organization such as, but not limited to, the following:

American Board of Electrodiagnostic Medicine (ABEM)
American Board of Psychiatry and Neurology's Added Qualifications in Clinical Neurophysiology (ABPN-CN)
American Board of Clinical Neurophysiology, Inc. (ABCN)
American Board of Neurophysiological Monitoring (ABNM)
American Board of Registration of Electrodiagnostic Technologists (ABRET)
American Society of Electroneurodiagnostic Technologists, Inc. (ASET)
American Board of Physical Therapy Specialties (ABPTS)

SURFACE ELECTROMYELOGRAM

Electromyographic studies performed with surface electrodes (ie, SEMG) instead of needle technology (ie, needle EMG) are not to be billed with the standard electrodiagnostic code (i.e., 95860).

In addition, surface electromyelogram (SEMG) studies described in this policy are reported using Healthcare Common Procedure Coding System (HCPCS) code S3900. It should not be confused with the type of EMG described in Current Procedural Terminology (CPT) code 51784, in which the physician places a pad in the anal or urethral sphincter and measures the electrical activity when the bladder is filled and during emptying.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, needle EMG and NCS are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in the medical policy are met. However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The US Food and Drug Administration (FDA) has approved several devices that are used to perform needle EMG.

The FDA has approved several devices, such as the NC-stat® (NeuroMetrix, Inc.; Waltham, MA) and Brevio® NCS-Monitor (NeuMed, Inc.; West Trenton, NJ) for measuring nerve conduction time. These devices typically function by applying a stimulus to an individual's peripheral nerve.

Description

NEEDLE ELECTROMYOGRAPHY (EMG)
EMG is the study and recording of the intrinsic electrical properties of skeletal muscles. EMG is performed to diagnose, define, and follow diseases of the peripheral nervous system and muscle. Needle EMG is performed by inserting an electrode through the skin into appropriate muscles, one at a time. The needle translates the amount and intensity of the electrical activity into waveforms that are displayed on a computer screen. Generally, the electrodes are of two types: monopolar or concentric. In addition, needle EMG can be performed as a part of intraoperative neurophysiological monitoring (INM), which monitors the integrity of neural pathways during surgeries where there is a potential for damage to neural integrity.

After the needle EMG is performed on the muscle, the data (the waveforms, sounds, and feel of the muscle) are analyzed to determine if additional muscles need to be studied. The muscles studied will vary depending upon the differential diagnosis and the ongoing synthesis of new information that is obtained while the test is being performed. The electromyographer relies on ongoing real-time clinical diagnostic evaluation when deciding whether to continue, modify, or conclude a needle EMG. This requires a comprehensive knowledge base of anatomy, physiology, and neuromuscular diseases, as well as an awareness of the influence of age, temperature, and body height on the results.

Needle EMG results reflect the integrity of the functioning connection between a nerve and its innervated muscle, as well as the integrity of the muscle itself. The axon innervating a muscle is primarily responsible for the muscle's volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG.

Neurogenic disorders can be distinguished from myopathic disorders by a carefully performed needle EMG. For example, both polymyositis and amyotrophic lateral sclerosis (ALS) produce manifest weakness; however, polymyositis carries a very different prognosis and treatment than ALS. A needle EMG is essential in making a distinction between the two disorders because the needle electrode allows the muscle's electrical characteristics at rest and during activity to be interpreted by the electromyographer. This interpretation includes an analysis of oscilloscope tracings and the characteristic sounds that are produced by electrical potentials. The final interpretation of the study is a combination of the individual's history, a physical examination, and the muscles tested. Similarly, classification of nerve trauma into axonal versus demyelinating categories, with corresponding differences in prognoses, is possible with a needle EMG.

NERVE CONDUCTION STUDIES (NCS) CONDUCTED WITH NEEDLE EMG
NCS is performed together with a needle EMG. NCS measures the electrical activity of muscles or the integrity of the functioning connection between a nerve and its innervated muscle, as well as the integrity of the muscle itself. The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) recommends that except under unique situations (e.g., presence of lymphedema, current use of anticoagulants), NCS and needle EMG should be performed together in a study for an accurate clinical diagnosis of peripheral nervous system disorders. The reporting of NCS and needle EMG study results should be integrated into a unifying diagnostic impression.

NCSs may be conducted without NEMG in some situations (e.g., individuals with significant lymphedema, with entrapment neuropathies, or on anticoagulants), but this should be the exception rather than the normal practice pattern.

SINGLE-FIBER EMG
In single-fiber needle EMG, a specially designed needle electrode is used to record and identify action potentials (APs) from individual muscle fibers. These recordings are used to calculate the neuromuscular jitter and the muscle fiber density (FD). Jitter is defined as the variability in time between activation of the motor nerve and generation of the muscle fiber AP; it reflects the normality of nerve-to-muscle transmission. Normal jitter varies among muscles and muscle fibers within individual muscles. To determine if jitter is abnormally increased, statistical analysis is performed from the recordings of a population of muscle fibers within each treated muscle. When neuromuscular transmission is sufficiently abnormal and nerve activation produces no muscle AP, blocking is seen. Increased jitter, blocking, or both may occur in a variety of primary disorders of neuromuscular transmission (e.g., myasthenia gravis). Jitter and FD may be measured in one or more muscles depending on the condition being evaluated and the results of the testing.

NEUROMUSCLAR JUNCTION TESTING

Neuromuscular junction testing, also known as repetitive nerve stimulation, is an electrodiagnostic test that is used to diagnose NMJ disorders such as myasthenia gravis, Lambert-Eaton myasthenic syndrome, and botulism. The test involves recording muscle responses to a series of nerve stimuli and may be used in association with NCSs of the same nerves.

SOMATOSENSORY-EVOKED POTENTIAL (SEP)

While motor and sensory NCS generally detect function in large-caliber peripheral nerve fibers, SEP tests conduction in central sensory pathways. SEP is an extension of the electrodiagnostic evaluation. SEP is a noninvasive study performed by repetitive submaximal stimulation of a sensory or mixed sensorimotor peripheral nerve. Amplitude, peak, and interpeak latency measurements with side-to-side comparisons are used to assess conduction abnormalities. SEP has proven useful in evaluating various conditions including, but not limited to: spinal cord trauma, subacute combined degeneration, nontraumatic spinal cord lesions, and multiple sclerosis.

H-REFLEX/F-WAVE STUDIES

Late response (H-reflex and F-wave study) testing is a type of NCS usually performed on nerves more proximal to the spine. The H-reflex involves conduction from the periphery to and from the spinal cord. The H-reflex study involves the assessment of the gastrocnemius/soleus muscle complex in the calf and is usually performed bilaterally due to the need to assess symmetrical results in determining abnormalities. The F-wave study is a late response similar to the H-reflex. F-wave studies are used to assess the proximal segments of the motor nerve function and are performed in combination with the examination of motor nerves. Both studies are helpful in diagnosing conditions of radiculopathies, plexopathies, polyneuropathies (particularly with multifocal conduction block, Guillain-Barré syndrome or chronic inflammatory demyelinating polyneuropathy), and proximal mononeuropathies. Late response studies are complementary to NCS and are performed during the same evaluation.

SURFACE EMG (SEMG)

A surface EMG (SEMG) is not the same as a conventional EMG. SEMG involves a noninvasive, computer-based technique that records the electrical impulses of the nerves and muscles through electrodes that are placed on or passed over the surface of the skin. SEMG differs from needle EMG with respect to technical requirements and electrical properties. SEMG electrodes measure from a wide area of muscle, have a relatively narrow frequency band, have low-signal resolution, and are highly susceptible to movement artifact. According to the AANEM, there are no clinical indications for the use of SEMG in the diagnosis and treatment of disorders of the nerves or muscles.

QUANTITATIVE SENSORY TESTING (QST)

QST is the noninvasive assessment and quantification of sensory nerve function, for which there are US Food and Drug Administration (FDA)--approved devices. QST involves psychophysical tests that are performed to provide a quantitative value to the subjective feeling of sensation. A transcutaneous electrical stimulus is used to determine the minimum stimulus that evokes sensation in the individual. Individuals are asked to identify the absence or presence of stimulus by undergoing a forced-choice protocol, with the threshold of perception as the measured response. Proponents of this test claim that neuropathies can be diagnosed by using transcutaneous electrical stimulus. Stimuli used in QST include touch, pressure, pain, temperature, and vibration.

SENSORY NERVE CONDUCTION THRESHOLD (sNCT) TESTING

The sNCT is a psychophysical assessment of both central and peripheral nerve functions. It measures the detection threshold of accurately calibrated sensory stimuli. This procedure is intended to evaluate and quantify function in both large and small caliber fibers for the purpose of detecting neurologic disease. Sensory perception and threshold detection are dependent on the integrity of both the peripheral sensory apparatus and peripheral-central sensory pathways. In theory, an abnormality detected by this procedure may signal dysfunction anywhere in the sensory pathway from the receptors, the sensory tracts, the primary sensory cortex, to the association cortex.

This procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials.

References

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Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

51784, 51785, 95860, 95861, 95863, 95864, 95865, 95867, 95868, 95869, 95870, 95872, 95874, 95885, 95886, 95887, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95928, 95929, 95937, 95938, 95939

NOT COVERED

92265, 95905, 95866, 0106T, 0107T, 0108T, 0109T, 0110T, 95933

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

MEDICALLY NECESSARY

See the Following Attachments for the Medically Necessary Indications:

Attachment	Procedures
B	Needle Electromyography and Nerve Conduction Studies
C	Electromyography of Anal or Urethral Sphincter
D	Needle Electromyography for Guidance in Conjunction with Chemodenervation
E	Neuromuscular Junction Testing
F	Somatosensory Evoked Potentials

Needle Electromyography of the Larynx (CPT 95865) IS CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:

J38.01 Paralysis of vocal cords and larynx, unilateral

J38.02 Paralysis of vocal cords and larynx, bilateral

R06.02 Shortness of breath

R13.12 Dysphagia, oropharyngeal phase

R13.13 Dysphagia, pharyngeal phase

R13.14 Dysphagia, pharyngoesophageal phase

R13.19 Other dysphagia

R49.0 Dysphonia

R49.8 Other voice and resonance disorders

Single Fiber Electromyography (CPT 95872) IS CONSIDERED MEDICALLY NECESSARY FOR THE FOLLOWING INDICATIONS:

G70.00 Myasthenia gravis without (acute) exacerbation

G70.01 Myasthenia gravis with (acute) exacerbation

G70.1 Toxic myoneural disorders

G70.2 Congenital and developmental myasthenia

G70.80 Lambert-Eaton syndrome, unspecified

G70.81 Lambert-Eaton syndrome in disease classified elsewhere

G70.89 Other specified myoneural disorders

G70.9 Myoneural disorder, unspecified

G73.1 Lambert-Eaton syndrome in neoplastic disease

G73.3 Myasthenic syndromes in other diseases classified elsewhere

H02.421 Myogenic ptosis of right eyelid

H02.422 Myogenic ptosis of left eyelid

H02.423 Myogenic ptosis of bilateral eyelids

H05.821 Myopathy of extraocular muscles, right orbit

H05.822 Myopathy of extraocular muscles, left orbit

H05.823 Myopathy of extraocular muscles, bilateral

H53.2 Diplopia

H53.8 Other visual disturbances

HCPCS Level II Code Number(s)

NOT MEDICALLY NECESSARY

S3900 Surface electromyography (EMG)

NOT COVERED

G0255 Current perception threshold/sensory nerve conduction threshold (sNCT) test, per limb, any nerve

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

12/10/2023

Version Issued Date:

4/22/2024

Version Reissued Date:

MA07.050

Medical Policy Bulletin

Medicare Advantage

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