Clinical UM Guideline


Subject:  Electromyography and Nerve Conduction Studies
Guideline #:  CG-MED-24Current Effective Date:  07/07/2015
Status:RevisedLast Review Date:  05/07/2015

Description

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:

Clinical Indications

 Medically Necessary:

  1. Needle EMG when performed with NCS at the same time of testing are considered medically necessary for diagnosing neuropathy with sensory loss, weakness or muscle atrophy for ANY of the following indications (1 thru 5):
    1. Unexplained peripheral neuropathy with pain of a neuropathic pattern, demonstrated sensory loss, or motor loss on physical examination; OR
    2. Neuropathy suspected to be due to trauma; OR
    3. When test results are expected to guide the management of conditions known to cause neuropathy, including but not limited to (a thru d):
      1. HIV-positive individuals with symptoms of neuropathy; or
      2. Mononeuropathies, such as Bell's palsy of the facial nerve; or
      3. Diabetics with persistent or progressive symptoms refractory to conventional treatments; or
      4. Individuals on dialysis or those considering dialysis; OR
    4. Suspected neural impingement or entrapment where symptoms are persistent or unresponsive to initial conservative treatments, as indicated by any of the following (a thru g):
      1. Carpal tunnel syndrome (when clinical documentation shows impingement symptoms refractory to activity modification and at least 4 weeks of wrist splint use); or
      2. Ulnar neuropathy at the elbow or wrist (when clinical documentation shows impingement symptoms refractory to activity modification and at least 4 weeks of elbow pad use); or
      3. Cervical or lumbar radiculopathy (when clinical documentation shows 4-6 weeks of failed conservative therapy, including physical therapy AND where the etiology of the radicular symptoms is not explained by MRI or other diagnostic studies); or
      4. Tarsal tunnel syndrome (when clinical documentation shows pain and numbness isolated to the foot); or
      5. Peroneal palsy with foot drop; or
      6. Suspected brachial or lumbosacral plexus impingement; or
      7. Other peripheral nerve entrapment syndromes; OR
    5. Significant clinical suspicion for any of the following conditions (a thru g):
      1. Amyotrophic lateral sclerosis; or
      2. Guillain-Barre syndrome; or
      3. Hereditary myopathies, (for example, muscular dystrophy); or
      4. Hereditary neuropathies, (for example, Charcot-Marie-Tooth disease); or
      5. Inflammatory myopathies, (for example, polymyositis, chronic inflammatory demyelinating polyneuropathy [CIDP]); or
      6. Inflammatory or idiopathic brachial or lumbosacral plexopathy; or
      7. Post-polio syndrome.
  2. Needle EMG when performed with NCS at the same time of testing are considered medically necessary for diagnosis of individuals with significant clinical suspicion for ANY of the following neuromuscular junction diseases (1 thru 3):
    1. Myasthenia gravis; OR
    2. Eaton-Lambert syndrome; OR
    3. Botulism.
      Note: 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 or weakness or sensory loss.
  3. NCS performed without needle EMG at the same time of testing is considered medically necessary for ANY of the following clinical indications (1 thru 7):
    1. Evaluation of suspected carpal or tarsal tunnel syndrome; OR
    2. Evaluation of suspected acute nerve injury (that is within 3 weeks of occurrence); OR
    3. For individuals on anticoagulant therapy (not merely anti-platelet treatments); OR
    4. For individuals with significant lymphedema; OR
    5. Evaluation of suspected peroneal palsy; OR
    6. Evaluation of thoracic outlet syndrome; OR
    7. For facial nerve monitoring in Bells palsy.
  4. Needle EMG performed without NCS at the same time of testing is considered medically necessary for the evaluation of suspected radiculopathy. 

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.

Coding

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.

CPT 
95860Needle electromyography; one extremity with or without related paraspinal areas
95861Needle electromyography; two extremities with or without related paraspinal areas
95863Needle electromyography; three extremities with or without related paraspinal areas
95864Needle electromyography; four extremities with or without related paraspinal areas
95867Needle electromyography; cranial nerve supplied muscle(s), unilateral
95868Needle electromyography; cranial nerve supplied muscle(s), bilateral
95869Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12)
95870Needle 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
95872Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied
95875Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s) metabolites(s)
95885Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited
95886Needle 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 
95887Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study 
95907Nerve conduction studies; 1-2 studies
95908Nerve conduction studies; 3-4 studies
95909Nerve conduction studies; 5-6 studies
95910Nerve conduction studies; 7-8 studies
95911Nerve conduction studies; 9-10 studies
95912Nerve conduction studies; 11-12 studies
95913Nerve conduction studies; 13 or more studies
95937Neuromuscular junction testing (repetitive stimulation, paired stimuli); each nerve, any one method
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2015]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2015]
 All diagnoses
  
Discussion/General Information

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:

References

Peer Reviewed Publications:

  1. Chang MH, Liu LH, Lee YC, et al. Comparison of sensitivity of transcarpal median motor conduction velocity and conventional conduction techniques in electrodiagnosis of carpal tunnel syndrome. Clin Neurophysiol. 2006; 117(5):984-991.
  2. Cho SC, Ferrante MA, Levin KH, et al. Utility of electrodiagnostic testing in evaluating patients with lumbosacral radiculopathy: an evidence-based review. Muscle Nerve. 2010; 42(2):276-282.
  3. Gooch CL, Weimer LH. The electrodiagnosis of neuropathy: basic principles and common pitfalls. Neurol Clin. 2007; 25(1):1-28.
  4. Hilburn JW. General principles and use of electrodiagnostic studies in carpal and cubital tunnel syndrome. With special attention to pitfalls and interpretation. Hand Clin. 1996; 12(2):205-221.
  5. Katz JN, Simmons BP. Carpal tunnel syndrome. N Engl J Med. 2002; 346(23):1807-1812.
  6. Kaufman MA. Differential diagnosis and pitfalls in electrodiagnostic studies and special tests for diagnosing compressive neuropathies. Orthop Clin North Am. 1996; 27(2):245-252.
  7. Marciniak C, Armon C, Wilson J, Miller R. Practice parameter: utility of electrodiagnostic techniques in evaluating patients with suspected peroneal neuropathy: an evidence-based review. Muscle Nerve. 2005; 31(4):520-527.
  8. Megerian JT, Kong X, Gozani SN. Utility of nerve conduction studies for carpal tunnel syndrome by family medicine, primary care, and internal medicine physicians. J Am Board Fam Med. 2007; 20(1):60-64.
  9. Mendell JR, Sahenk Z. Painful sensory neuropathy. Southern Reg Med CTR. September 19th 2003. N Engl J Med. 2003; 348(13):1243-1255.
  10. Mondelli M, Aretini A, Arrigucci U, et al. Clinical findings and electrodiagnostic testing in 108 consecutive cases of lumbosacral radiculopathy due to herniated disc. Neurophysiol Clin. 2013; 43(4):205-215.
  11. Tankisi H, Pugdahl K, Euglsang-Frederiksen A, et al. Pathophysiology inferred from electrodiagnostic nerve tests and classification of polyneuropathies. Suggested guidelines. Clin Neurophysiol. 2005; 116(7):1571-1580.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Agency for Healthcare Research and Quality (AHRQ). Chapell R, Bruening W, Mitchell MD, et al. Diagnosis and treatment of worker-related musculoskeletal disorders of the upper extremity. Health Technology Assessments. 2002. No. 62.
  2. American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation. (AAN, AANEM, AAPMR). Practice parameter: Electrodiagnostic studies in ulnar neuropathy at the elbow. Neurology. 1999; 52(4):688-690. Available at: http://onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-4598(199903)22:3%3C408::AID-MUS16%3E3.0.CO;2-7/abstract.Accessed on April 7, 2015.
  3. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Model Policy for Needle Electromyography and Nerve Conduction Studies. 2010. Available at:  http://www.aanem.org/getmedia/29c2a525-d8b5-4a59-8ac4-04bafafab972/Model_Policy_NCS_EMG_062810.pdf.aspx. Accessed on April 7, 2015.
  4. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Position statement. Approved September 2005. Muscle Nerve. 2006; 33(33):436-439. Available at: http://www.aanem.org/getmedia/9b4fa3d5-c127-4c3d-9296-b650e443b2cc/ProperPerformance.pdf.aspx. Accessed on April 7, 2015.
  5. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM, formerly AAEN). Recommended Policy for Electrodiagnostic Medicine. Rochester, MN. September 1997 and updated 2004.  Endorsed by the American Academy of Neurology, the American Academy of Physical Medicine and Rehabilitation, and the American Association of Neuromuscular and Electrodiagnostic Medicine. Available at:  http://www.aanem.org/getmedia/b0af02d9-943c-4f78-aa91-91da3f582b49/Recommended_Policy_EDX_Medicine_07152010.pdf.aspx. Accessed on April 7, 2015.
  6. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Reporting the results of needle EMG and nerve conduction studies: an educational report. ©2005 American Association of Neuromuscular & Electrodiagnostic Medicine. Available at: http://www.aanem.org/getmedia/670b50d3-bb67-4d22-85f5-517b7221ca25/RptResultsEMGNCS.pdf.aspx. Accessed on April 7, 2015.
  7. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Technologists conducting nerve conduction studies and somatosensory evoked potential studies independently to be reviewed by a physician at a later time. May 1999. Updated and approved June 2009. Available at: http://www.aanem.org/getmedia/0ecf23a8-1e4e-41a0-b244-b818e3af5333/TechsNCSSEP062509.pdf.aspx. Accessed on April 7, 2015.
  8. England JD, Gronseth GS, Franklin G, et al. Distal symmetric polyneuropathy: a definition for clinical research: report of the American Academy of Neurology, the American Association of Neuromuscular and Electrodiagnostic Medicine (AAEN) and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2005; 64(2):199-207.
  9. Institute for Clinical Systems Improvement (ICSI). Pain, Chronic; Assessment and Management of. 2013. Available at: https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_neurological_guidelines/pain/. Accessed on April 7, 2015.
  10. Jablecki CK, Andary MT, Floeter MK, et al.; American Academy of Neurology, America Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Neurology. 1993; 43(11):2404-2405. Republished: Neurology. 2002; 58(11):1589-1592.
Index

Electromyography, Nerve Conduction Studies
Electrophysiological Studies
EMG/NCS
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.

History
StatusDateAction
Revised05/07/2015Medical Policy & Technology Assessment Committee (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.
Reviewed11/13/2014MPTAC review. The Discussion section and References were updated.
Reviewed11/14/2013MPTAC review. The Discussion section and References were updated.
Reviewed11/08/2012MPTAC review. Updated Reference section.  Updated Coding section with 01/01/2013 CPT changes.
Revised11/17/2011MPTAC 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.
Reviewed02/17/2011MPTAC review. References were updated.
Reviewed02/25/2010MPTAC 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.
Reviewed02/26/2009MPTAC 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.
Reviewed02/21/2008MPTAC review. References were updated.
Revised03/08/2007MPTAC 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.
Reviewed12/07/2006MPTAC review. References and coding were updated. 
Revised12/01/2005MPTAC review.  Revision based on Harmonization: Pre-merger Anthem and Pre-merger WellPoint.
Pre-Merger OrganizationsLast Review DateDocument NumberTitle
Anthem, Inc.  No document
Anthem BCBS  No document
WellPoint Health Networks, Inc.07/14/2005Clinical GuidelineElectromyography and Nerve Conduction Study (EMG/NCS)