Clinical UM Guideline

 

Subject: Electromyography and Nerve Conduction Studies
Guideline #:  CG-MED-24 Publish Date:    12/27/2017
Status: Revised Last Review Date:    11/02/2017

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.
        *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.
  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.
  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.

Needle EMG or NCS is considered not medically necessary for all other conditions, including but not limited to, back pain without radiculopathy, or headaches when there is no suspicion of an underlying disorder of the cranial nerves.

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

 

95860

Needle electromyography; 1 extremity with or without related paraspinal areas

95861

Needle electromyography; 2 extremities with or without related paraspinal areas

95863

Needle electromyography; 3 extremities with or without related paraspinal areas

95864

Needle electromyography; 4 extremities with or without related paraspinal areas

95867

Needle electromyography; cranial nerve supplied muscle(s), unilateral

95868

Needle electromyography; cranial nerve supplied muscle(s), bilateral

95869

Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12)

95870

Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters

95872

Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied

95875

Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s) metabolites(s)

95885

Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited

95886

Needle 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

95887

Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study

95907

Nerve conduction studies; 1-2 studies

95908

Nerve conduction studies; 3-4 studies

95909

Nerve conduction studies; 5-6 studies

95910

Nerve conduction studies; 7-8 studies

95911

Nerve conduction studies; 9-10 studies

95912

Nerve conduction studies; 11-12 studies

95913

Nerve conduction studies; 13 or more studies

95937

Neuromuscular junction testing (repetitive stimulation, paired stimuli); each nerve, any 1 method

 

 

ICD-10 Diagnosis

 

 

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 provides 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 (AANEM), in its Recommended Policy for Electrodiagnostic Medicine (2017), 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. In the 2015 position statement Proper Performance and Interpretation of Electrodiagnostic Studies, AANEM states that except for 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:

When NCSs are performed without needle EMG, the additional and complementary information provided by the needle EMG results (except in limited circumstances) is not available. Without the information provided by the needle EMG examination, valuable data that may be essential to establishing an accurate diagnosis is missing. ….Additionally, patients typically need to have both NCSs and needle EMG to ensure that an underlying medical condition is not being missed.

In another AANEM document, the Model Policy for Needle Electromyography and Nerve Conduction Studies, updated in 2016, the following was noted:

The necessity and reasonableness of the following uses of needle EMG studies have not been established:

  1. exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions
  2. definitive diagnostic conclusions based on paraspinal EMG in regions bearing scar of past surgeries (e.g., previous laminectomies)
  3. pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of radiculopathy
  4. needle EMG testing shortly after trauma, before needle EMG abnormalities would have reasonable time to develop
  5. surface and macro EMGs
  6. multiple uses of needle EMG in the same patient at the same location for the purpose of optimizing botulinum toxin injections.

Currently, the published literature does not support that the use of EMG and NCS testing for other conditions, such as headaches without suspected cranial nerve pathology, or back pain without suspected radiculopathy provides additional meaningful clinical information. The North American Spine Society (NASS, 2013) provides the following Choosing Wisely® recommendation:

Don’t use electromyography (EMG) and nerve conduction studies (NCS) to determine the cause of axial lumbar, thoracic or cervical spine pain.

References

Peer Reviewed Publications:

  1. Callaghan BC, Price RS, Feldman EL. Distal symmetric polyneuropathy: a review. JAMA. 2015; 314(20):2172-2181.
  2. 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.
  3. 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.
  4. Gooch CL, Weimer LH. The electrodiagnosis of neuropathy: basic principles and common pitfalls. Neurol Clin. 2007; 25(1):1-28.
  5. 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.
  6. Katz JN, Simmons BP. Carpal tunnel syndrome. N Engl J Med. 2002; 346(23):1807-1812.
  7. 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.
  8. Lazaro RP. Electromyography in musculoskeletal pain: A reappraisal and practical considerations. Surg Neurol Int. 2015; 6:143.
  9. 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.
  10. 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.
  11. Mendell JR, Sahenk Z. Painful sensory neuropathy. Southern Reg Med CTR. September 19th 2003. N Engl J Med. 2003; 348(13):1243-1255.
  12. 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.
  13. 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. American Academy of Neurology (AAN), American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) and the American Academy of Physical Medicine and Rehabilitation (AAPM&R). 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 September 9, 2017.
  2. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). AANEM Policy Statement on Electrodiagnosis for Distal Symmetric Polyneuropathy. Approved July 2017. Available at: https://www.aanem.org/getmedia/9e615547-4532-446e-9a96-dbe0f7b7345f/EDX-in-DSP.pdf. Accessed on September 9, 2017.
  3. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Model Policy for Needle Electromyography and Nerve Conduction Studies. Updated and reapproved January 2016. Available at: https://www.aanem.org/getmedia/65934187-d91e-4336-9f3c-50522449e565/Model-Policy.pdf. Accessed on November 5, 2017.
  4. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). AANEM. Proper Performance and Interpretation of Electrodiagnostic Studies. [Corrected]. Muscle Nerve. 2015; 51(3):468-471. Available at: https://www.aanem.org/getmedia/bd1642ce-ec01-4271-8097-81e6e5752042/Position-Statement_Proper-Performance-of-EDX_-2014.pdf. Accessed on September 9, 2017.
  5. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Recommended Policy for Electrodiagnostic Medicine. Updated July 2017. Endorsed by the American Academy of Neurology (AAN), the American Academy of Physical Medicine and Rehabilitation (AANEM). Available at: https://www.aanem.org/getmedia/b4192939-448e-499d-927e-6444558f19f1/Recommended_Policy_EDX_Medicine.pdf. Accessed on September 9, 2017.
  6. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Reporting the results of needle EMG and nerve conduction studies: An educational report. Updated and approved May 2014. Available at: https://www.aanem.org/getmedia/15908152-4080-4e2a-b39e-8b7b36255d0e/RptResultsEMGNCS-pdf.pdf. Accessed on September 9, 2017.
  7. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Nerve conduction studies and somatosensory evoked potential studies independently to be reviewed by a physician at a later time. Modified and approved November 2014. Available at: https://www.aanem.org/getmedia/9cd02f93-4ec1-4019-aa94-844ac4507c32/Technologists_Conducing_NCS_SEP-clean-version.pdf. Accessed on September 9, 2017.
  8. England JD, Gronseth GS, Franklin G, et al. Distal symmetric polyneuropathy: a definition for clinical research: report of the American Academy of Neurology (AAN), the American Association of Neuromuscular and Electrodiagnostic Medicine (AAEM) and the American Academy of Physical Medicine and Rehabilitation (AAPM&R). Neurology. 2005; 64(2):199-207.
  9. American Academy of Neurology, America Association of Neuromuscular and Electrodiagnostic Medicine and the American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: Summary statement. Reaffirmed March 2015. Available at: http://www.aanem.org/getmedia/df604eb2-1bbe-4cf8-a256-cc62f9128e5d/CTS_Reaffirmed.pdf. Accessed on September 9, 2017.
  10. North American Spine Society (NASS). Choosing Wisely. NASS – EMG nerve conduction studies to determine cause of spine pain. October 9, 2013. Available at: http://www.choosingwisely.org/clinician-lists/nass-emg-nerve-conduction-studies-to-determine-cause-of-spine-pain/. Accessed on September 5, 2017.
Websites for Additional Information
  1. American Academy of Orthopaedic Surgeons (AAOS). OrthoInfo: Electrodiagnostic Testing. Last reviewed June 2017. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00270. Accessed on September 9, 2017.
  2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Choosing Wisely: Five Things Physicians and Patients Should Question. February 10, 2015 and July 31, 2017. Available at: http://www.choosingwisely.org/societies/american-association-of-neuromuscular-electrodiagnostic-medicine/. Accessed on September 9, 2017.
  3. National Institute of Health (NIH). National Institute of Neurological Disorders and Stroke. Neurological Diagnostic Tests and Procedures Fact Sheet. March 1, 2005. Available at: https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Neurological-Diagnostic-Tests-and-Procedures-Fact. Accessed on September 9, 2017.
Index

Electromyography, Nerve Conduction Studies
Electrophysiological Studies
EMG/NCS
Nerve Conduction Studies, Electromyography
Nerve Conduction Velocity (NCV) Studies

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History