a) Nerve conduction studies (NCS) test the peripheral nervous system for:

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1 Health Plan Coverage Policy ARBenefits Approval: 11/02/2011 Effective Date: 01/01/2012 Revision Date: 09/18/2013 Comments: Code additions only. Title: Electrodiagnostic Testing Document: ARB0256 Public Statement: 1) Electrodiagnostic testing is generally covered. 2) Electrodiagnostic Testing includes: a) Nerve conduction studies (NCS) test the peripheral nervous system for: i) integrity (is it all connected up correctly?), 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) Electrodiagnostic testing as screening for diabetic neuropathy or other neuropathy in asymptomatic patients is not covered. Medical Policy Statement: 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. Page 1 of 7

2 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 (unilateral, bilateral) (see selection criteria below) 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 Page 2 of 7

3 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. 6) Surface EMG is covered only for testing the anal or urethral sphincters in children under the age of 14. Any other use is considered investigational and is not covered. Limits: 1) Quantitative sensory testing (QST) (0106T-0110T) is considered experimental and 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 and 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 and 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 and 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 and 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 and 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 and 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. Page 3 of 7

4 8) NCS studies are considered experimental and investigational for screening for polyneuropathy of diabetes or end-stage renal disease in asymptomatic individuals. 9) NCS studies are considered experimental and investigational for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease. 10) EMG by other than needle is considered experimental and investigational, except for testing of the anal or urethral sphincters in children under the age of 14. Background: 1) Electrodiagnostic testing should be performed by a physician with specific training in the conduct and interpretation of the tests. These tests should be conducted and interpreted in a face-to-face encounter 11. 2) Number of tests to be performed 14 : The following table lists the American Association of Electrodiagnostic Medicine's recommendations concerning a reasonable maximum number of NCS, needle EMG and other electrodiagnostic studies per diagnostic category needed for a physician to render a diagnosis: 3) Electrodiagnostic Testing Chart Needle Electromyography Nerve Conduction Studies Other Electromyographic Studies Indications Number of Tests Motor NCS with and/or without F wave Sensory NCS H-Reflex Neuromuscular Junction Testing (Repetitive Stimulation) Carpal Tunnel Unilateral Carpal Tunnel Bilateral Radiculopathy Mononeuropathy Polyneuropathy/ Mononeuropathy Multiplex Myopathy Plexopathy Neuromuscular Junction Tarsal Tunnel Syndrome (Uni) Tarsal Tunnel Syndrome (Bil) Weakness, Fatigue, Cramps or Twitching (focal) Weakness, Page 4 of 7

5 Fatigue, Cramps, or Twitching (general) Pain, Numbness, or Tingling (Uni) Pain, Numbness, or Tingling (Bil) Nerve conduction studies performed more frequently than once a year may be reviewed for medical necessity. Motor and sensory nerve conduction studies and late responses (F-wave and H- reflex studies) are often complementary and performed during the same evaluation. F-wave and H-reflex studies are performed to evaluate nerve conduction in portions of the nerve more proximal (near the spine) and, therefore, inaccessible to direct assessment using conventional techniques. Electrical stimulation is applied on the skin surface near a nerve site in a manner that sends impulses both proximally and distally. Characteristics of the responses are assessed, including latency. Late responses provide information in the evaluation of radiculopathies, plexopathies, polyneuropathies (especially in suspected Guillain- Barré syndrome or chronic inflammatory demyelinating polyneuropathy), and proximal mononeuropathies. In some cases, they may be the only abnormal study. H-Reflex Studies: Typically, only 2 H-reflex studies are performed in a given examination. H-reflex studies usually must be performed bilaterally because symmetry of responses is an important criterion for abnormality. When a bilateral H-reflex study is performed, the entire procedure must be repeated, increasing examiner time and effort; there are no economies of scale in multiple H-reflex testing. H-reflex studies usually involve assessment of the gastrocnemius/soleus muscle complex in the calf. Bilateral gastrocnemius/soleus H-reflex abnormalities are often early indications of spinal stenosis, or bilateral S1 radiculopathies. In rare instances, H reflexes need to be tested in muscles other than the gastrocnemius/soleus muscle, e.g., in the upper limbs. In conditions such as cervical radiculopathies or brachial plexopathies, an H-reflex study can be performed in the arm (flexor carpi radialis muscle). Other muscles that may be tested, although rarely, are the intrinsic small muscles of the hand and foot. F-Wave Studies: Although the set-up for an F-wave study is similar to the set-up for a motor NCS, the testing is carried out separately from the motor NCS, utilizing different Page 5 of 7

6 machine settings and separate stimuli. A large number of responses (at least 10) are obtained. The number of F-wave studies, which need to be performed on a given person, depends on the working diagnosis and the electrodiagnostic findings already in evidence. It may be appropriate in the same person to perform some motor NCS with an F-wave and others without an F-wave. References: Arkansas BlueCross BlueShield Coverage policy Manual; Nerve conduction studies (NCS), Electromyelography (EMG) at: 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): 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): 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): 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): 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): Megerian JT, Gozani SN. Upper extremity nerve conduction studies in diabetic patients with the NC-stat. Diabetes Technol Ther. 2006;8(2): Katz RT. NC-stat as a screening tool for carpal tunnel syndrome in industrial workers. J Occup Environ Med. 2006;48(4): Marciniak C, Armon C, Wilson J, Miller R. Practice parameter: Utility of electrodiagnostic techniques in evaluating patients with suspected peroneal neuropathy. An evidencebased review. Muscle Nerve. 2005;31(4): 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): Page 6 of 7

7 American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve. 2006;33(3): Available at: Garssen MP, van Doorn PA, Visser GH. Nerve conduction studies in relation to residual fatigue in Guillain-Barré syndrome. J Neurol. 2006;253(7): Work Loss Data Institute. Carpal tunnel syndrome (acute & chronic). Corpus Christi, TX: Work Loss Data Institute; American Medical Association (AMA). Appendix J -- Electrodiagnostic medicine listing of sensory, motor, and mixed nerves. Current Procedural Terminology (CPT) Professional ed. Chicago, IL: AMA; 2007: 499. Physician Request for Reconsideration: This coverage policy is the result of the clinical data, peer-reviewed material, documented trials, and other non-member specific clinical data available to and reviewed by the ARBenefits Health Plan Coverage Policy review panel. In the event that the treating physician has additional clinical data, peer-reviewed material, documented trials, or non-member specific clinical data, it should be provided to the Employee Benefits Division, P.O. Box 15610, Little Rock, AR 72231, Attn: Coverage Policy Review panel c/o Chief Health Services Officer. Application to Products This policy applies to ARBenefits. Consult ARBenefits Summary Plan Description (SPD) for additional information. Page 7 of 7