Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Policy #:MA07.050f

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

NEEDLE ELECTROMYOGRAPHY (EMG)
Needle electromyography (EMG), which provides amplitude, latency, configuration, and conduction velocity data, is considered medically necessary and, therefore, covered for the following suspected indications:
  • Mononeuropathy and polyneuropathy (metabolic, degenerative, hereditary)
  • Motor neuronopathy (including amyotrophic lateral sclerosis [ALS])
  • Myopathy (including polymyositis and dermatomyositis; myotonic and congenital myopathies)
  • Nerve compression syndromes (including carpal tunnel syndrome and other focal compressions)
  • Neuromuscular junction disorders (myasthenia gravis)
  • Plexopathy (idiopathic, trauma, infiltration)
  • Radiculopathy (cervical, lumbosacral)

(Refer to Table 1 for diagnoses code list)

In addition, needle EMG is considered medically necessary and, therefore, covered for localization prior to the administration of either of the following:
  • Botulinum toxin type A (Botox) (when used for Company-covered indications)
    • Multiple uses of a needle EMG in the same individual at the same location of the same limb for the purpose of optimizing botulinum toxin injections has not been supported.
  • Phenol or other substances used for nerve blocking or chemodenervation

Needle EMG when conducted and interpreted at the same time as a nerve conduction study (NCS) is considered medically necessary and, therefore, covered. However, there are circumstances when needle EMG is not performed in conjunction with NCS. Examples of medically necessary, and, therefore, covered NCS performed without needle EMG include, but are not limited to, the following:
  • Follow-up evaluation after previous electrodiagnostic evaluation
  • Individual is currently on anticoagulation therapy
  • Individual has lymphedema
  • Individual is unable to tolerate needle EMG
    • Documentation in the individual's medical record must support intolerance to needle EMG.
Table 1
Please refer to attachments A-K of this policy for American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines or for diagnoses that support medical necessity
Attachment ARecommended guidelines for maximum number of needle EMG
Attachment BICD-10 code range A05.1 - G61.89
Attachment CICD-10 code range G62.0 - I69.041
Attachment DICD-10 code range I69.042 - M48.26
Attachment EICD-10 code range M48.27 - M62.831
Attachment FICD-10 code range M62.838 - S12.001B
Attachment GICD-10 code range S12.001D - S14.151S
Attachment HICD-10 code range S14.152A - S32.059A
Attachment IICD-10 code range S32.059B - S54.8X1D
Attachment JICD-10 code range S54.8X1S - S94.30XS
Attachment KICD-10 code range S94.31XA - S94.92XS

NOT MEDICALLY NECESSARY

NEEDLE ELECTROMYOGRAPHY (EMG)
Needle EMG for any other indication is considered not medically necessary and, therefore, not covered. Examples of indications include, but are not limited to:
  • Exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions
  • Definitive diagnostic conclusions based on paraspinal needle EMG in regions bearing scar of past surgeries (e.g., previous laminectomies)
  • Pattern-setting limited limb muscle examinations, without paraspinal muscle testing for the diagnosis of radiculopathies
  • Premature needle EMG testing after trauma when EMG changes have not taken place
  • Multiple uses of needle EMG in the same individual at the same location of the same limb for the purpose of optimizing botulinum toxin injections have not been supported.

EXPERIMENTAL/INVESTIGATIONAL

SURFACE ELECTROMYELOGRAMS
Although the US Food and Drug Administration (FDA) has approved devices for surface electromyelogram (SEMG), the Company has determined that the safety and/or effectiveness of this procedure cannot be established by review of the available published peer-reviewed literature. Therefore, SEMG is considered experimental/investigational by the Company and not covered.

PROFESSIONAL AND TECHNICAL REIMBURSEMENT
  • Only physicians (MD/DO) are eligible to receive reimbursement for the professional component of EMG. Physicians may also receive reimbursement for the technical component if they performed that service.
  • Non-physician professional providers (e.g., physical therapists) are only eligible to receive reimbursement for the technical component of EMG.

STATE OF NEW JERSEY
In the state of New Jersey, as defined by the scope of practice regulations, only a physician may perform needle EMG studies.

REQUIRED DOCUMENTATION

Documentation of the performing professional provider's qualifications must be made available to the Company upon request.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

MINIMUM STANDARDS FOR NEEDLE ELECTROMYOGRAPHY (EMG)

The Company has adopted the minimum standards for needle EMG as defined by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Minimum standards include the following:
  • Testing should be performed using equipment that assesses all parameters of the recorded signals.
    • Studies that are performed with devices designed only for screening, rather than diagnosing, are not eligible under this policy.
  • The number of tests performed should be the minimum that are necessary to establish an accurate diagnosis, which may include evaluation of one or more nerves that have normal test results for comparative purposes.

Please refer to Attachment A of this policy for the AANEM recommendations regarding the maximum number of studies that should be performed for each condition, as well as examples of clinical situations where additional testing may be appropriate. These recommendations should not apply if the individual requires evaluation by more than one consultant (.ie., a second opinion or an expert opinion at a tertiary care center) in a given year or if the individual requires evaluation for a second diagnosis in a given year.

CLINICAL SPECIALIZATION PROGRAMS

Eligible professional providers performing a needle EMG should have sufficient knowledge and experience in needle EMG. Competency to perform needle EMG can be demonstrated through training from a clinical specialization program. Candidates are able to demonstrate their level of competence from a certification organization such as, but not limited to, the following:
  • American Board of Electrodiagnostic Medicine (ABEM)
  • American Board of Psychiatry and Neurology's Added Qualifications in Clinical Neurophysiology (ABPN-CN)
  • American Board of Clinical Neurophysiology, Inc. (ABCN)
  • American Board of Neurophysiological Monitoring (ABNM)
  • American Board of Registration of Electrodiagnostic Technologists (ABRET)
  • American Society of Electroneurodiagnostic Technologists, Inc. (ASET)
  • American Board of Physical Therapy Specialties (ABPTS)

SURFACE ELECTROMYELOGRAM

Electromyographic studies performed with surface electrodes (ie, SEMG) instead of needle technology (ie, needle EMG) are not to be billed with the standard electrodiagnostic code (i.e., 95860).

In addition, surface electromyelogram (SEMG) studies described in this policy are reported using Healthcare Common Procedure Coding System (HCPCS) code S3900. It should not be confused with the type of EMG described in Current Procedural Terminology (CPT) code 51784, in which the physician places a pad in the anal or urethral sphincter and measures the electrical activity when the bladder is filled and during emptying.

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, needle EMG is covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in the medical policy are met. However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The US Food and Drug Administration (FDA) has approved several devices that are used to perform needle EMG.

Description

NEEDLE ELECTROMYOGRAPHY (EMG)

EMG is the study and recording of the intrinsic electrical properties of skeletal muscles. EMG is performed to diagnose, define, and follow diseases of the peripheral nervous system and muscle. Needle EMG is performed by inserting an electrode through the skin into appropriate muscles, one at a time. The needle translates the amount and intensity of the electrical activity into waveforms that are displayed on a computer screen. Generally, the electrodes are of two types: monopolar or concentric. In addition, needle EMG can be performed as a part of intraoperative neurophysiological monitoring (INM), which monitors the integrity of neural pathways during surgeries where there is a potential for damage to neural integrity.

After the needle EMG is performed on the muscle, the data (the waveforms, sounds, and feel of the muscle) are analyzed to determine if additional muscles need to be studied. The muscles studied will vary depending upon the differential diagnosis and the ongoing synthesis of new information that is obtained while the test is being performed. The electromyographer relies on ongoing real-time clinical diagnostic evaluation when deciding whether to continue, modify, or conclude a needle EMG. This requires a comprehensive knowledge base of anatomy, physiology, and neuromuscular diseases, as well as an awareness of the influence of age, temperature, and body height on the results.

Needle EMG results reflect the integrity of the functioning connection between a nerve and its innervated muscle, as well as the integrity of the muscle itself. The axon innervating a muscle is primarily responsible for the muscle's volitional contraction, survival, and trophic functions. Thus, interruption of the axon will alter the EMG.

Neurogenic disorders can be distinguished from myopathic disorders by a carefully performed needle EMG. For example, both polymyositis and amyotrophic lateral sclerosis (ALS) produce manifest weakness; however, polymyositis carries a very different prognosis and treatment than ALS. A needle EMG is essential in making a distinction between the two disorders because the needle electrode allows the muscle's electrical characteristics at rest and during activity to be interpreted by the electromyographer. This interpretation includes an analysis of oscilloscope tracings and the characteristic sounds that are produced by electrical potentials. The final interpretation of the study is a combination of the individual's history, a physical examination, and the muscles tested. Similarly, classification of nerve trauma into axonal versus demyelinating categories, with corresponding differences in prognoses, is possible with a needle EMG.

SINGLE-FIBER EMG
In single-fiber needle EMG, a specially designed needle electrode is used to record and identify action potentials (APs) from individual muscle fibers. These recordings are used to calculate the neuromuscular jitter and the muscle fiber density (FD). Jitter is defined as the variability in time between activation of the motor nerve and generation of the muscle fiber AP; it reflects the normality of nerve-to-muscle transmission. Normal jitter varies among muscles and muscle fibers within individual muscles. To determine if jitter is abnormally increased, statistical analysis is performed from the recordings of a population of muscle fibers within each treated muscle. When neuromuscular transmission is sufficiently abnormal and nerve activation produces no muscle AP, blocking is seen. Increased jitter, blocking, or both may occur in a variety of primary disorders of neuromuscular transmission (e.g., myasthenia gravis). Jitter and FD may be measured in one or more muscles depending on the condition being evaluated and the results of the testing.

NERVE CONDUCTION STUDIES (NCS) CONDUCTED WITH NEEDLE EMG

NCS is performed together with a needle EMG. NCS measures the electrical activity of muscles or the integrity of the functioning connection between a nerve and its innervated muscle, as well as the integrity of the muscle itself. The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) recommends that except under unique situations (e.g., presence of lymphedema, current use of anticoagulants), NCS and needle EMG should be performed together in a study for an accurate clinical diagnosis of peripheral nervous system disorders. The reporting of NCS and needle EMG study results should be integrated into a unifying diagnostic impression.

SURFACE EMG (SEMG)

A surface EMG (SEMG) is not the same as a conventional EMG. SEMG involves a noninvasive, computer-based technique that records the electrical impulses of the nerves and muscles through electrodes that are placed on or passed over the surface of the skin. SEMG differs from needle EMG with respect to technical requirements and electrical properties. SEMG electrodes measure from a wide area of muscle, have a relatively narrow frequency band, have low-signal resolution, and are highly susceptible to movement artifact. According to the AANEM, there are no clinical indications for the use of SEMG in the diagnosis and treatment of disorders of the nerves or muscles.
References

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). EMG laws by state. [AANEM Web site]. 01/31/2017. Available at: http://www.aanem.org/Advocacy/EMG-Laws-by-State. Accessed May 09, 2018.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Model policy for needle electromyography and nerve conduction studies. [AANEM Web site]. 12/31/2012. Available at: https://www.aanem.org/getmedia/89f84ac9-28ec-48af-847f-720b772cb370/2014-Model_Policy_NCS_EMG_.pdf. Accessed January 11, 2016.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. [AANEM Web site]. June 2014. Available at: https://www.aanem.org/getmedia/bd1642ce-ec01-4271-8097-81e6e5752042/Position-Statement_Proper-Performance-of-EDX_-2014.pdf. Accessed may 09, 2018.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Recommended policy for electrodiagnostic medicine. [AANEM Web site]. 08/30/2014. Available at:
https://www.aanem.org/getmedia/3275d71c-81dc-4b23-96a7-03173ecf8446/Recommended_Policy_EDX_Medicine_062810.pdf Accessed May 09, 2018.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Technology review: The use of surface EMG in the diagnosis and treatment of nerve and muscle disorders. [AANEM Web site]. October 2008. Available at: http://www.aanem.org/getmedia/5397eea1-3de0-469d-a293-24bd7e2f1050/tech_rvw_surface_emg.PDF.aspx Accessed May 09, 2018.

Bittman B, Cram JR. Surface electromyography: an electrophysiologic alternative in pain management. Presented at the American Pain Society; 1992; Illinois.

Cram JR, Lloyd J, Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom. 1994;41(4-Jan):41-45.

Ellestad SM, Nagle RV, Boesler DR, et al. Electromyographic and skin resistance responses to osteopathic manipulative treatment for low-back pain. J Am Osteopath Assoc. 1988;88(8):991-997.

De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve. 1993;16(2):210-216.

Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. 2011;3(10):920-928.

Humphrey AR, Nargol AV, Jones AP, et al. The value of electromyography of the lumbar paraspinal muscles in discriminating between chronic-low-back-pain sufferers and normal subjects. Eur Spine J. 2005;14(2):175-184.

Hung CC, Shen TW, Liang CC, et al. Using surface electromyography (SEMG) to classify low back pain based on lifting capacity evaluation with principal component analysis neural network method. Conf Proc IEEE Eng Med Biol Soc. 2014;2014:18-21.

Hu Y, Kwok JW, Tse JY, et al. Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation. Spine J. 2014;14(6):1049-1056.

Hu Y, Siu SH, Mak JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyogr Kinesiol. 2010;20(2):246-255.

Hu Y, Kwok JW, Tse JY, et al. Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation. Spine J. 2014;14(6):1049-1056.

Jones SL, Hitt JR, Desarno MJ, et al. Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations. Exp Brain Res. 2012;221(4):413-426.

Mohseni Bandpei MA, Rahmani N, Majdoleslam B, et al. Reliability of surface electromyography in the assessment of paraspinal muscle fatigue: an updated systematic review. J Manipulative Physiol Ther. 2014;37(7):510-521.

Neblett R, Brede E, Mayer TG, et al. What is the best surface EMG measure of lumbar flexion-relaxation for distinguishing chronic low back pain patients from pain-free controls? Clin J Pain. 2013;29(4):334-340.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35081: Electromyography (EMG) and nerve conduction studies. [Novitas Solutions, Inc. Web site]. (Original: 05/28/09). Revised: 10/01/17. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35081&ver=59&Date=10%2f05%2f2015&DocID=L35081&bc=iAAAAAgBAAAA&. Accessed May 09, 2018.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35503: Intraoperative neurophysiological testing. [Novitas Solutions, Inc. Web site]. 04/12/2018. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35003&ver=43&Keyword=+Intraoperative+neurophysiological+testing.&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAABABAAAA&. Accessed May 09, 2018.

Peach JP, McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine.1998;23(10):1117-1123.

Pullman SL, Goodin DS, Marquinez AI, et al. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcomittee of the American Academy of Neurology. Neurology.2000;55(2):171-177.

Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther.1998;78(8):838-851.

Sheeran L, Sparkes V, Caterson B, et al. Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain: classification analysis. Spine (Phila Pa 1976). 2012;37(8):E486-495.

US Food and Drug Administration (FDA). Needle Electrodes. 510(k) summary. [FDA Web site]. 10/07/10. Available at: Center for Devices and Radiological Health. Available at: http://www.fda.gov. Accessed January 11, 2016.

Van Damme B, Stevens V, Perneel C, et al. A surface electromyography based objective method to identify patients with nonspecific chronic low back pain, presenting a flexion related movement control impairment. J Electromyogr Kinesiol. 2014;24(6):954-964.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

92265, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95874, 95885, 95886, 95887


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachments B, C, D, E, F, G, H, I, J, K


HCPCS Level II Code Number(s)



EXPERIMENTAL/INVESTIGATIONAL

S3900 Surface electromyography (EMG)



Revenue Code Number(s)

0922 Other diagnostic services. Electromyelogram


Coding and Billing Requirements


Cross References

Attachment A: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: Recommended Guidelines for Electrodiagnostic Studies

Attachment B: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10

Attachment C: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment D: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment E: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment F: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment G: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment H: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment I: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment J: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes

Attachment K: Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
Description: ICD-10 Codes



Related Documents




Policy History

Revisions from MA07.050f:
11/20/2019This policy has been reissued in accordance with the Company's annual review process.
10/01/2019This version of the policy will become effective 10/01/2019. The following ICD-10 codes have been revised in the policy: M50.120.

Revisions from MA07.050e
10/01/2018This version of the policy will become effective 10/01/2018. The following ICD-10 codes have been added to the policy:G51.31, G51.32, G51.33, G51.39, G71.00, G71.01, G71.02, G71.09, H02.151, H02.152, H02. 153, H02.154, H02.155, H02.156, H02.159, M79.10, M79.11, M79.12, M79.18. The following ICD-10 codes have been termed from the policy: G51.3, G71.0, M79.1.

Revisions from MA07.050d
07/23/2018This version of the policy will become effective 07/23/2018. The following ICD-10 codes have been added to the policy: M50.020, M50.021, M50.022, M50.023, M50.120, M50.121, M50.122, M50.123, M50.220, M50.221, M50.222, M50.223, M50.320, M50.321, M50.322, M50.323, M50.820, M50.821, M50.822, M50.823, M50.920, M50.921, M50.922, M50.923. The following ICD-10 codes have been termed from the policy: I60.0, I60.21, I60.22, M50.02, M50.12, M50.22, M50.32, M50.82, M50.92.

Revisions from MA07.050c
10/01/2017This version of the policy will become effective 10/01/2017.

The following ICD-10 CM code has been termed from this policy:

M48.06 Spinal stenosis, lumbar region
The following ICD-10 CM codes have been added to this policy: (medically necessary)

G12.23 Primary lateral sclerosis
G12.24 Familial motor neuron disease
G12.25 Progressive spinal muscle atrophy
M48.061 Spinal stenosis, lumbar region without neurogenic claudication
M48.062 Spinal stenosis, lumbar region with neurogenic claudication

The following ICD-10 CM narratives have been revised in this policy:

M33.00
FROM: Juvenile dermatopolymyositis, organ involvement unspecified
TO: Juvenile dermatomyositis, organ involvement unspecified

M33.01
FROM: Juvenile dermatopolymyositis with respiratory involvement
TO: Juvenile dermatomyositis with respiratory involvement

M33.02
FROM: Juvenile dermatopolymyositis with myopathy
TO: Juvenile dermatomyositis with myopathy

M33.09
FROM: Juvenile dermatopolymyositis with other organ involvement
TO: Juvenile dermatomyositis with other organ involvement

M33.10
FROM: Other dermatopolymyositis, organ involvement unspecified
TO: Other dermatomyositis, organ involvement unspecified

M33.11
FROM: Other dermatopolymyositis with respiratory involvement
TO:Other dermatomyositis with respiratory involvement

M33.12
FROM: Other dermatopolymyositis with myopathy
TO: Other dermatomyositis with myopathy

M33.19
FROM: Other dermatopolymyositis with other organ involvement
TO: Other dermatomyositis with other organ involvement

Revisions from MA07.050b
06/07/2017This policy has been reissued in accordance with the Company's annual review process.
10/01/2016This version of the policy will become effective 10/01/2016.

The following ICD-10 CM codes have been added to this policy:
    G56.03 Carpal tunnel syndrome, bilateral upper limbs
    G56.13 Other lesions of median nerve, bilateral upper limbs
    G56.23 Lesion of ulnar nerve, bilateral upper limbs
    G56.33 Lesion of radial nerve, bilateral upper limbs
    G56.43 Causalgia of bilateral upper limbs
    G56.83 Other specified mononeuropathies of bilateral upper limbs
    G56.93 Unspecified mononeuropathy of bilateral upper limbs
    G57.03 Lesion of sciatic nerve, bilateral lower limbs
    G57.13 Meralgia paresthetica, bilateral lower limbs
    G57.23 Lesion of femoral nerve, bilateral lower limbs
    G57.33 Lesion of lateral popliteal nerve, bilateral lower limbs
    G57.43 Lesion of medial popliteal nerve, bilateral lower limbs
    G57.53 Tarsal tunnel syndrome, bilateral lower limbs
    G57.63 Lesion of plantar nerve, bilateral lower limbs
    G57.73 Causalgia of bilateral lower limbs
    G57.83 Other specified mononeuropathies of bilateral lower limbs
    G57.93 Unspecified mononeuropathy of bilateral lower limbs
    G61.82 Multifocal motor neuropathy

The following ICD-10 CM narratives have been revised in this policy:

S54.8X1A
FROM: Unspecified injury of other nerves at forearm level, right arm, initial encounter
TO: Injury of other nerves at forearm level, right arm, initial encounter

S54.8X1D
FROM: Unspecified injury of other nerves at forearm level, right arm, subsequent encounter
TO: Injury of other nerves at forearm level, right arm, subsequent encounter

S54.8X1S
FROM: Unspecified injury of other nerves at forearm level, right arm, sequela
TO: Injury of other nerves at forearm level, right arm, sequela

S54.8X2A
FROM: Unspecified injury of other nerves at forearm level, left arm, initial encounter
TO: Injury of other nerves at forearm level, left arm, initial encounter

S54.8X2D
FROM: Unspecified injury of other nerves at forearm level, left arm, subsequent encounter
TO: Injury of other nerves at forearm level, left arm, subsequent encounter

S54.8X2S
FROM: Unspecified injury of other nerves at forearm level, left arm, sequela
TO: Injury of other nerves at forearm level, left arm, sequela

S54.8X9A
FROM: Unspecified injury of other nerves at forearm level, unspecified arm, initial encounter
TO: Injury of other nerves at forearm level, unspecified arm, initial encounter

S54.8X9D
FROM: Unspecified injury of other nerves at forearm level, unspecified arm, subsequent encounter
TO: Injury of other nerves at forearm level, unspecified arm, subsequent encounter

S54.8X9S
FROM: Unspecified injury of other nerves at forearm level, unspecified arm, sequela
TO: Injury of other nerves at forearm level, unspecified arm, sequela

Revisions from MA07.050a
08/01/2016This version of the policy will become effective 08/01/2016.

The medically necessary coverage criteria is unchanged; however, applicable diagnosis codes have been added to the policy.

Revisions from MA07.050
02/18/2015The policy has been reviewed and reissued to communicate the Company’s continuing position on Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
01/01/2015This is a new policy.






Version Effective Date: 10/01/2019
Version Issued Date: 10/02/2019
Version Reissued Date: 11/22/2019