Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Electro-Diagnostic testing is generally covered.

2)    Electro-Diagnostic Testing includes:

a)    Nerve Conduction Studies (NCS) test the peripheral nervous system for:

i)       Integrity, and

ii)     Diagnosis of diseases of the nerves.

b)    Electromyography (EMG) is the study and recording of the electrical properties of skeletal muscles. This is done to test for diseases in the muscles or the nerves leading to those muscles – usually in cases of weakness. This is carried out with a needle electrode.

3)    These services may be performed in the physician’s office and may be subject to deductible and coinsurance.

4)    Nerve Conduction Study and EMG performed by Occupational/Physical Therapists are covered only if they are rendered by a therapist who has had special training in performing this type of testing.  Reimbursement to the therapist is limited to the technical component of the procedure only.  In order for the technical component of the test to be reimbursed to the therapist the NCS must be:

a)    Ordered by a physician;

b)    Performed under the supervision of a physician; and

c)     Interpreted by a qualified physician with training in the interpretation of nerve conduction studies.

1)    Nerve conduction studies (NCS) are considered medically necessary in either of the following indications: 

a)    For diagnosis of peripheral nerve diseases; OR

b)    For 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.

2)    Repetitive nerve stimulation testing is considered medically necessary for the diagnosis of neuromuscular junction disorders (e.g., myasthenia gravis, myasthenic syndrome).

3)    Nerve conduction studies have been found to be medically necessary for the following conditions:

a)    Carpal tunnel syndrome (see selection criteria below), or other compressive mononeuropathy

b)    Diabetic neuropathy

c)     Disorders of peripheral nervous system

d)    Disturbance of skin sensation

e)    Fasciculation

f)      Joint pain

g)    Muscle weakness

h)    Myopathy

i)       Myositis

j)      Nerve root compression

k)     Neuritis

l)       Neuromuscular conditions

m)  Pain in limb

n)    Plexopathy

o)    Spinal cord injury

p)    Swelling and cramps

q)    Trauma to nerves

4)    For evaluation of individuals suspected of having unilateral carpal tunnel syndrome, the following services are considered  medically necessary: 

a)    Sensory conduction studies of the median nerve and one other sensory nerve in the symptomatic limb; AND

b)    Motor conduction studies of the median nerve recording from the thenar muscles and of one other nerve in the symptomatic limb to include measurement of distal latencies; AND

c)     If one of the studies of the median nerve is abnormal, F wave testing of the median nerve to assess proximal function; AND

d)    If one of the studies of the median nerve is abnormal, a test of the contralateral median nerve to assess for bilaterality.

5)    Blink reflex testing is considered medically necessary to evaluate disease involving the 5th or 7th cranial nerves or brainstem. Blink reflexes are considered experimental and investigational for all other indications.

Codes Used In This BI:

1)    Quantitative sensory testing (QST) (0106T – 0110T) is considered experimental/investigational for the management of individuals with neuropathy or any other diagnoses because its diagnostic value has not been established.

2)    Current Perception Threshold (CPT) (no CPT or HCPCS codes found) testing is considered experimental/investigational because the effectiveness and clinical applicability of this testing in diagnosing and/or managing diabetic peripheral neuropathy or other diseases has not been established.

3)    Voltage-actuated sensory nerve conduction threshold (VsNCT) testing is considered experimental/investigational because its clinical value has not been established in the peer reviewed published medical literature.

4)    Surface scanning electromyography (EMG), paraspinal surface EMG, or macro EMG is considered experimental/investigational as a diagnostic test for evaluating low back pain or other thoracolumbar segmental abnormalities such as soft tissue injury, intervertebral disc disease, nerve root irritation and scoliosis, and for all other indications because the reliability and validity of these tests have not been established. HAYES D

5)    Portable surface EMG devices are considered experimental/investigational for diagnosis and/or monitoring of nocturnal bruxism and all other indications because the reliability and validity of these tests have not been demonstrated.

6)    Spinoscopy (Spinoscope, Spinex Corp.), a diagnostic technique that combines surface scanning EMG with video recordings, is considered experimental/investigational as the clinical value of this diagnostic technique has not been validated.

7)    F-wave study to evaluate the median nerve at the carpal tunnel in carpal tunnel syndrome is considered experimental/investigational since there is no proven value to this study for this condition. F-wave study for testing the proximal median nerve to assess proximal function in the presence of abnormality at the carpal tunnel is appropriate.

8)    Examination/NCS studies using the NC-stat monitor, the Brevio NCS monitor, the Neural-Scan, and other automated portable hand-held devices are considered experimental/investigational.

9)    NCS studies are considered experimental/investigational for screening for polyneuropathy of diabetes or end-stage renal disease. [in asymptomatic individuals]

10) NCS studies are considered experimental/investigational for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease.

11) EMG by other than needle is considered experimental/investigational.

1. Garssen MP, Blok JH, van Doorn PA, Visser GH. Conduction velocity distribution in neurologically well-recovered but fatigued Guillain-Barre syndrome patients. Muscle Nerve. 2006; 33(2):177-182.
2. Leffler CT, Gozani SN, Cros D. Median neuropathy at the wrist: Diagnostic utility of clinical findings and an automated electrodiagnostic device. J Occup Environ Med. 2000; 42(4):398-409.
3. Vinik AI, Emley MS, Megerian JT, Gozani SN. Median and ulnar nerve conduction measurements in patients with symptoms of diabetic peripheral neuropathy using the NC-stat system. Diabetes Technol Ther. 2004; 6(6):816-284.
4. Elkowitz SJ, Dubin NH, Richards BE, Wilgis EF. Clinical utility of portable versus traditional electrodiagnostic testing for diagnosing, evaluating, and treating carpal tunnel syndrome. Am J Orthop. 2005; 34(8):362-364.
5. Kong X, Gozani SN, Hayes MT, Weinberg DH. NC-stat sensory nerve conduction studies in the median and ulnar nerves of symptomatic patients. Clin Neurophysiol. 2006; 117(2):405-413.
6. Megerian JT, Gozani SN. Upper extremity nerve conduction studies in diabetic patients with the NC-stat. Diabetes Technol Ther. 2006; 8(2):258-260.
7. Katz RT. NC-stat as a screening tool for carpal tunnel syndrome in industrial workers. J Occup Environ Med. 2006; 48(4):414-418.
8. 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.
9. Patel AT, Gaines K, Malamut R, et al. Usefulness of electrodiagnostic techniques in the evaluation of suspected tarsal tunnel syndrome: An evidence-based review. Muscle Nerve. 2005; 32(2):236-240.
10. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve. 2006; 33(3):436-439. Available at: http://www.aanem.org/documents/ProperPerformance.pdf
11. Garssen MP, van Doorn PA, Visser GH. Nerve conduction studies in relation to residual fatigue in Guillain-Barré syndrome. J Neurol. 2006; 253(7):851-856.
12. Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi, TX: Work Loss Data Institute; 2006.
13. American Medical Association (AMA). Appendix J -- Electrodiagnostic medicine listing of sensory, motor, and mixed nerves. Current Procedural Terminology (CPT) 2007. Professional ed. Chicago, IL: AMA; 2007: 499.

Addendum:

• Effective 11/01/2016: Added specified reimbursement criteria for Physical and Occupational therapists, performing the study.
• Effective 11/01/2017: Inclusion of other compressive mononeuropathies (in addition to carpal tunnel syndrome)

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.