ELECTROMYOGRAPHY (EMG), NEEDLE, NERVE CONDUCTION STUDIES (NCS) AND QUANTITATIVE SENSORY TESTING (QST)

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1 AND QUANTITATIVE SENSORY TESTING (QST) Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. Description: Electromyography (EMG): EMG refers to the recording and study of electrical activity of muscles using a needle electrode inserted into the muscle. Needle electromyography procedures include the interpretation of electrical waveforms measured by equipment that produces both visual and auditory components of electrical signals recorded from the muscle(s) studied by the needle electrode. Nerve Conduction Studies (NCS): NCS evaluate the conduction of nerves by means of electrodes on the skin, or, in some cases, needle electrodes. The nerve is stimulated with a mild electrical impulse and the resulting electrical activity is recorded by other electrodes. The distance between electrodes and the time it takes for electrical impulses to travel between them are used to calculate the nerve conduction velocity. NCS may also be referred to as nerve conduction velocity tests (NCV). NCS are typically performed together with a needle EMG and performed by a provider properly trained in electrodiagnostic medicine. Specialties with this training are neurology, physical medical and rehabilitation and physiatry. O59.20.docx Page 1 of 6

2 Description: (cont.) Automated Nerve Conduction Tests: Automated nerve conduction tests are performed with portable devices that allow NCS to be done in an office without specialized training, rather than performed in conjunction with a needle EMG in a laboratory. The automated devices use computer software to deliver, measure and analyze the responses from conduction studies and provide a detailed report for review by the physician. Automated point-of-care nerve conduction tests have been investigated to assist in the diagnosis of carpal tunnel syndrome and peripheral neuropathy. Quantitative Sensory Testing (QST): QST systems are used for noninvasive assessment and quantification of sensory nerve function in persons with symptoms of, or the potential for, neurologic damage or disease. QST combines the objective physical sensory stimuli with the subjective individual response and requires that the individual is alert, cooperative and able to follow directions. Because QST is psychophysical, the results have greater inherent variability which makes them more difficult to standardize and reproduce. QST has been investigated to evaluate smaller myelinated and unmyelinated sensory nerves that may show pathologic changes before the pathology can be detected in the myelinated large fibers evaluated by the gold standard of needle EMG and NCS. Quantitative sensory tests include: Current perception threshold (CPT) testing (also referred to as sensory nerve conduction threshold [snct]) testing Pressure-specified sensory device testing Thermal threshold testing Vibration perception threshold testing O59.20.docx Page 2 of 6

3 Criteria: For surface EMG, see BCBSAZ Medical Coverage Guideline, Electromyography, Surface (SEMG). Needle EMG with NCS is considered medically necessary with documentation of a detailed neurologic, vascular and musculoskeletal physical examination of the affected area and ANY of the following: 1. Numbness/tingling OR radiculopathy (pain, muscle weakness, atrophy, depression of deep tendon reflexes or sensory impairment to pin prick, 2 point discrimination or light touch) with documentation of ALL of the following: Failure of medically supervised conservative treatment (e.g., rest, analgesics, NSAIDS, physical therapy, spinal manipulation, if appropriate) specific to the individual s symptoms for 30 days or greater Other diagnostic tests (i.e., MRI, CT, vascular studies, lab tests) are not appropriate (e.g., carpal tunnel syndrome) or are unable to determine etiology of symptoms 2. Suspected hereditary or acquired neuropathy prior to nerve biopsy 3. Suspected hereditary or acquired myopathy prior to muscle biopsy Testing that fails to meet the above criteria is considered not medically necessary and not eligible for coverage. Needle EMG with NCS performed on an individual with chronic medical conditions with known complications of neuropathy are considered not medically necessary and not eligible for coverage. These chronic conditions include, but are not limited to: Diabetic neuropathy End-stage renal disease HIV neuropathy O59.20.docx Page 3 of 6

4 Criteria: (cont.) Needle EMG with NCS performed to diagnose a neuropathy in an individual without signs or symptoms of a neuropathy is considered screening and, therefore, a benefit plan exclusion and not eligible for coverage. Needle EMG with NCS for all other indications not previously listed is considered experimental or investigational based upon: NCS performed without a needle EMG are considered experimental or investigational based upon: Automated nerve conduction tests for all indications are considered experimental or investigational based upon: O59.20.docx Page 4 of 6

5 Quantitative sensory testing for all indications is considered experimental or investigational based upon: These tests include, but are not limited to: Vibration perception threshold testing Pressure-specified sensory device testing Thermal threshold testing Current perception threshold testing (CPT) Resources: BCBS Association Medical Policy Reference Manual. Quantitative Sensory Testing. Reissue date 09/13/2012, issue date 05/31/ BCBS Association Medical Policy Reference Manual. Automated Point-of-Care Nerve Conduction Tests. Re-issue date 06/14/2012, issue date 04/09/ American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) Position Statement. Proper Performance and Interpretation of Electrodiagnostic Studies. Muscle Nerve ;33(3): American Medical Association Current Procedural Terminology, (CPT ) ;Appendix J: Bendszus M, Wessig C, Reiners K, Bartsch AJ, Solymosi L, Koltzenberg M. MR imaging in the differential diagnosis of neurogenic foot drop. AJNR Am J Neuroradiol Aug 2003;24(7): External Consultant Review. Manager of Medical Economics; American Association of Neuromuscular & Electrodiagnostic Medicine. 06/2008. O59.20.docx Page 5 of 6

6 Resources: (cont.) 7. External Consultant Review. Physical Medicine and Rehabilitation. 06/10/ InterQual Care Planning Criteria Procedures Adult. Electromyography (EMG) and Nerve Conduction Studies (NCS). 9. Jarvik JG, Yuen E, Kliot M. Diagnosis of carpal tunnel syndrome: electrodiagnostic and MR imaging evaluation. Neuroimaging Clin N Am Feb 2004;14(1):93-102, viii. 10. Medicine AAoNaE, Position Statement. Who is Qualified to Practice Electrodiagnostic Medicine? Srinivasan J, Amato AA. Myopathies. Phys Med Rehabil Clin N Am May 2003;14(2): FDA 510K Summary for Medi-DX 7000 : - FDA-approved indication: For the quantitative detection of sensory neurological impairments. The population of subjects for whom this device may be used for diagnostic purposes would include any individual capable of communicating their perception of cutaneous sensation. O59.20.docx Page 6 of 6