Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)

Policy #:07.03.09o

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member’s contract.

MEDICALLY NECESSARY

NEEDLE ELECTROMYOGRAPHY (EMG)
Needle 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 because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury. 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.
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 (i.e., 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)

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 (ie, 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.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, needle EMG is covered under the medical benefits of the Company’s 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 Codes

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




Policy History

07.03.09o

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.

07.03.09n
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.


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A

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