Commercial

Medical Policy

Notification

Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies

Notification Issue Date:

This version of the policy will become effective 03/21/2022.

Policy language was added to indicate that for the sole purpose of diagnosing or confirming radiculopathy, nerve conduction studies (NCS) when not conducted and interpreted at the same time as a needle electromyography (EMG) will be considered Not Medically Necessary and, therefore, not covered.

Title:

Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies

Policy #:

07.03.18t

Policy

MEDICALLY NECESSARY

Nerve conduction studies (NCS) that provide real-time conduction, amplitude, and latency/velocity data are considered medically necessary and, therefore, covered for the following:

Localization of focal neuropathies or compressive lesions, such as carpal tunnel syndrome, ulnar neuropathies, or root lesions
Diagnosis and prognosis of traumatic nerve lesions
Diagnosis or confirmation of suspected generalized neuropathies (e.g., diabetic, uremic, metabolic, toxic, or immunologic)
Repetitive nerve stimulation to assist in the diagnosis of neuromuscular junction disorders (e.g., myasthenia gravis, myasthenic syndrome)
Differential diagnosis of symptom-based complaints (e.g., pain, weakness, disturbance in skin sensation [e.g., burning or tingling]) related to peripheral nerve injuries or diseases that affect the peripheral nervous system

(Refer to Table 1 for diagnoses code list)

NCS when conducted and interpreted at the same time as needle electromyography (EMG) are 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

Motor and/or sensory nerve conduction, using preconfigured electrode arrays (with an F-wave study),
(Current Procedural Terminology [CPT] code 95905), for the diagnosis of carpal tunnel syndrome is considered medically necessary and, therefore, covered with the following limits:

Once per limb studied, per individual, per year, for a high pretest probability (80% or more) of a diagnosis of carpal tunnel syndrome
Instruments and electrodes used for testing have relevant US Food and Drug Administration (FDA) approvals and published peer-reviewed scientific data to support their use
Cannot be billed in conjunction with any other NCS codes on the same individual, on the same day

Motor NCS (with and without an F-wave study) and sensory NCS at a frequency of two sessions per calendar year are considered medically necessary and, therefore, covered for most conditions requiring such testing. Please refer to Attachment A of this policy for more detailed information on the recommendations regarding the maximum number of studies that are appropriate for certain conditions, as well as examples of clinical situations where additional testing is considered medically necessary.

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 A	Recommended guidelines for maximum number of NCS
Attachment B	ICD-10 code range A05.1 - G61.89
Attachment C	ICD-10 code range G62.0 - I69.041
Attachment D	ICD-10 code range I69.042 - M48.26
Attachment E	ICD-10 code range M48.27 - M62.831
Attachment F	ICD-10 code range M62.838 - S12.001B
Attachment G	ICD-10 code range S12.001D - S14.151S
Attachment H	ICD-10 code range S14.152A - S32.059A
Attachment I	ICD-10 code range S32.059B - S54.8X1D
Attachment J	ICD-10 code range S54.8X1S - S94.30XS
Attachment K	ICD-10 code range S94.31XA - S94.92XS

NOT MEDICALLY NECESSARY

NCS, when not conducted and interpreted at the same time as needle EMG for the sole purpose of diagnosing or confirming radiculopathy are considered not medically necessary and, therefore, not covered.

NCS for all other uses are 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 not medically necessary NCS include, but are not limited to:

Motor NCS with an F-wave study for screening for carpal tunnel syndrome
NCS for screening for polyneuropathy of diabetes or end-stage renal disease (ESRD) and for testing for the sole purpose of monitoring disease intensity or treatment efficacy in these conditions

EXPERIMENTAL/INVESTIGATIONAL

Although the FDA has approved devices for quantitative sensory testing (QST), the Company has determined that the safety and/or effectiveness of this procedure for diagnosing and/or managing a disease cannot be established by review of the available published peer-reviewed literature. Therefore, QST for diagnosing and/or managing a disease is considered experimental/investigational by the Company and not covered.

AUTOMATED COMPUTERIZED PORTABLE HAND-HELD DEVICES

Noninvasive electrodiagnostic testing with automated computerized portable hand-held devices, which are incapable of real-time waveform display and analysis, whether or not it is performed as part of an evaluation and management (E&M) service, is not eligible for separate reimbursement.

PROFESSIONAL AND TECHNICAL REIMBURSEMENT

Only physicians (MD/DO) are eligible to receive reimbursement for the professional component of NCS.
Nonphysician professional providers are only eligible to receive reimbursement for the technical component of NCS.

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 professional provider's office, hospital, nursing home, home health agencies, therapies, other health care professionals, 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

BILLING GUIDELINES

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

CPT Procedure codes 95907, 95908, 95909, 95910, 95911, 95912, and 95913 would not be appropriate to report for nerve conduction studies (NCS) using preconfigured electrode array(s).

MINIMUM STANDARDS FOR NERVE CONDUCTION STUDIES (NCS)

The Company has adopted the minimum standards for NCS 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 for coverage under this policy.
The number of nerves tested should be the minimum necessary to address the clinical issue; this 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 assess their level of competence from a credentialing 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)

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, NCS are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met. However, uses for NCS that have been identified in this policy as not medically necessary or experimental/investigational are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several devices, such as the NC-stat® (NeuroMetrix, Inc.; Waltham, MA) and Brevio® NCS-Monitor (NeuMed, Inc.; West Trenton, NJ) for measuring nerve conduction time. These devices typically function by applying a stimulus to an individual's peripheral nerve.

Description

NERVE CONDUCTION STUDIES (NCS)

NCS can be used to evaluate both motor and sensory nerve function, and aids in the diagnosis of peripheral nerve injuries (e.g., carpal tunnel syndrome, sciatica) and diseases that affect the peripheral nervous system (e.g., hereditary progressive muscular dystrophy, myasthenia gravis). In addition, NCS can be performed as part of intraoperative neurophysiological monitoring (INM), which monitors the integrity of neural pathways during high-risk surgeries. During NCS, a nerve is stimulated electrically to assess the speed (conduction velocity and/or latency), size (amplitude), and shape of the response. Usually, surface electrodes are used for both stimulating and recording, although needle electrodes may be required in special cases.

Motor NCS are performed by applying electrical stimulation at various points along the course of a motor nerve while recording the electrical response from an appropriate muscle. Sensory NCS are performed by applying electrical stimulation near a sensory nerve and recording the response from a distant site along the nerve. Mixed NCS are performed by applying electrical stimulation near a nerve that contains both motor and sensory fibers and recording the response from a different location along that same nerve.

The results of NCS reflect the integrity and function of both the axon of a nerve and the myelin sheath that covers it. Axonal damage or dysfunction generally results in loss of potential amplitude of the nerve or muscle; demyelination leads to a prolonged conduction time. Results of NCS should document the nerves that were evaluated, the distance between the stimulation and recording sites, the conduction velocity, the latency values, and the amplitude, all of which help establish the final diagnosis.

NCS CONDUCTED WITH NEEDLE ELECTROMYOGRAM (EMG)
NCS are performed together with a needle EMG. EMG studies measure 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, 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 EMG study results should be integrated into a unifying diagnostic impression.

Radiculopathies cannot be diagnosed by NCS alone; needle EMG must be performed to confirm a radiculopathy. Therefore, these studies should be performed together by one physician supervising and/or performing all aspects of the study.

NCS USING AUTOMATED COMPUTERIZED PORTABLE HAND-HELD DEVICES
Noninvasive electrodiagnostic testing with automated computerized portable hand-held devices has been developed to provide NCS in a variety of clinical settings to evaluate systemic and entrapment neuropathies (e.g., diabetic peripheral neuropathy, carpal tunnel syndrome). However, automated computerized portable hand-held devices are incapable of real-time waveform display and analysis. Such devices were originally approved by the US Food and Drug Administration (FDA) as an adjunct to, and not as a replacement for, conventional NCS methods.

OTHER RELATED ELECTRODIAGNOSTIC STUDIES

The following are examples of additional electrodiagnostic studies that may be considered as an extension of an NCS electrodiagnostic evaluation:

LATE RESPONSES: H-REFLEX STUDIES AND F-WAVE STUDIES
Late responses, such as H-reflex and F-wave studies, are performed to evaluate nerve conduction in portions of the nerve that are more proximal to, or near, the spine or brainstem. Due to their locations, these nerves are inaccessible to direct assessment using conventional techniques. This is to be contrasted with the evaluation of the distal peripheral nerves, which is accomplished by NCS. Late responses are often complementary to motor and sensory NCS and are performed during the same evaluation. 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 response, including latency, are assessed. Late responses provide information in the evaluation of radiculopathies, plexopathies, polyneuropathies, and proximal mononeuropathies.

Although H-reflex studies are usually performed on the gastrocnemius/soleus muscle complex in the calf, other areas can also be assessed. Abnormalities on H-reflex studies usually indicate spinal stenosis or spinal radiculopathies. F-wave studies are used to obtain a larger number of responses in the motor nerves that are examined. In some instances, it may be appropriate for an individual to perform some motor NCS with F-wave studies and some without. Current evidence in published peer-reviewed literature does not support the use of F-waves, in isolation, to diagnose radiculopathy.

NEUROMUSCULAR JUNCTION STUDIES
Neuromuscular junction studies involve the recording of a muscle response to a series of nerve stimuli before and, at variable intervals, after exercise or transmission of high-frequency stimuli. These tests are used in association with motor and sensory NCS of the same nerves.

QUANTITATIVE SENSORY TESTING (QST)
QST is the noninvasive assessment and quantification of sensory nerve function, for which there are FDA–approved devices. QST involves psychophysical tests that are performed to provide a quantitative value to the subjective feeling of sensation. A transcutaneous electrical stimulus is used to determine the minimum stimulus that evokes sensation in the individual. Individuals are asked to identify the absence or presence of stimulus by undergoing a forced-choice protocol, with the threshold of perception as the measured response. Proponents of this test claim that neuropathies can be diagnosed by using transcutaneous electrical stimulus. Stimuli used in QST include touch, pressure, pain, temperature, and vibration. Four methods of QST include:

Sensory Nerve Conduction Threshold (sNCT) Testing
Current Perception Threshold Testing (Pain Perception Threshold [PPT] and Pain Tolerance Threshold [PTT])
Voltage-Actuated Sensory Nerve Conduction Threshold (VsNCT)
Pressure-Specified Sensory Testing

There is a paucity of available published peer-reviewed literature to establish and support the safety and effectiveness of QST. Follow-up studies are needed.

SOMATOSENSORY-EVOKED POTENTIAL (SSEP)
While motor and sensory NCS generally detect function in large-caliber peripheral nerve fibers, SSEP tests conduction in central sensory pathways. SSEP is an extension of the electrodiagnostic evaluation. SSEP is a noninvasive study performed by repetitive submaximal stimulation of a sensory or mixed sensorimotor peripheral nerve. Amplitude, peak, and interpeak latency measurements with side-to-side comparisons are used to assess conduction abnormalities. SSEP has proven useful in evaluating various conditions including, but not limited to: spinal cord trauma, subacute combined degeneration, nontraumatic spinal cord lesions, and multiple sclerosis.

References

American Academy of Neurology. Quantitative Sensory Testing. 2003 (reaffirmed 2022); https://www.aan.com/Guidelines/home/GuidelineDetail/87. Accessed September 11, 2023.

American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. February 29, 2016. Available at: https://www.aaos.org/globalassets/quality-and-practice-resources/carpal-tunnel/cts_cpg_4-25-19.pdf. Accessed September 8, 2023.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Evidenced-Based Review: Use of Surface Electromyography in the Diagnosis and Study of Neuromuscular Disorders. [AANEM Web site]. October 2008. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/use-of-surface-electromyography-in-the-diagnosis-and-study-of-neuromuscular-disorders. Accessed September 8, 2023.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Model Policy for Nerve Conduction Studies and Needle Electromyography. [AANEM Web site]. December 2022. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/model-policy-for-nerve-conduction-studies-and-needle-electromyography. Accessed September 8, 2023.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. [AANEM Web site]. January 2020. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/proper-performance-and-interpretation-of-electrodiagnostic-studies. Accessed September 8, 2023.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Recommended policy for electrodiagnostic medicine. [AANEM Web site]. January 2023. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/recommended-policy-for-electrodiagnostic-medicine. Accessed September 8, 2023.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Technologists Conducting NCSs and SEPs Independently to be Reviewed by a Physician at a Later Time [AANEM Web Site]. August 2020. Available at: https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/technologists-conducting-ncss-and-seps-independently-to-be-reviewed-by-a-physician-at-a-later-time. Accessed September 11, 2023.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for sensory Nerve Conduction Threshold Tests (sNCTs) (160.23). 2004; https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=270&ncdver=2. Accessed September 11, 2023.

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):984-91.

Fowler JR, Munsch M, Tosti R, et al. Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as the reference standard. J Bone Joint Surg Am. 2014;96(17):e148.

Ghosh PS, Sorenson EJ. Diagnostic yield of electromyography in children with myopathic disorders. Pediatr Neurol. 2014;51(2):215-9.

Gooch CL, Weimer LH. The electrodiagnosis of neuropathy: basic principles and common pitfalls. Neurol Clin. 2007;25(1):1-28.

Homan MM, Franzblau A, Werner RA, et al. Agreement between symptom surveys, physical examination procedures and electrodiagnostic findings for the carpal tunnel syndrome. Scand J Work Environ Health. 1999;25(2):115-24.

Kang PB, McMillan HJ, Kuntz NL, et al. Utility and practice of electrodiagnostic testing in the pediatric population: An AANEM consensus statement. Muscle Nerve. 2020;61(2):143-55.

Lee DH, Claussen GC, Oh S. Clinical nerve conduction and needle electromyography studies. J Am Acad Orthop Surg. 2004;12(4):276-87.

Marciniak C, Armon C, Wilson J, et al. Practice parameter: utility of electrodiagnostic techniques in evaluating patients with suspected peroneal neuropathy: an evidence-based review. Muscle Nerve. 2005;31(4):520-7.

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):205-15.

Novitas Solutions, Inc. Local Coverage Determination (LCD). L35081: Nerve Conduction Studies and Electromyography. (Original: 10/01/2015). Revised: 10/31/2019. Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=35081. Accessed September 8, 2023.

Novitas Solutions, Inc. Local Coverage Article (LCA). A54095: Billing and Coding: Nerve Conduction Studies and Electromyography. (Original: 10/01/2015). Revised: 01/01/2023. Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=54095&ver=41&. Accessed September 8, 2023.

Olney RK, Lewis RA, Putnam TD, et al. Consensus criteria for the diagnosis of multifocal motor neuropathy. Muscle Nerve. 2003;27(1):117-21.

Rabie M, Jossiphov J, Nevo Y. Electromyography (EMG) accuracy compared to muscle biopsy in childhood. J Child Neurol. 2007;22(7):803-8.

Tulipan JE, Lutsky KF, Maltenfort MG, et al. Patient-Reported Disability Measures Do Not Correlate with Electrodiagnostic Severity in Carpal Tunnel Syndrome. Plast Reconstr Surg Glob Open. 2017;5(8):e1440.

U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health. NeuroMetrix ADVANCE™. 510(k) summary. [FDA Web site]. 04/25/08. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf7/K070109.pdf. Accessed September 19, 2023.

U.S. Food and Drug Administration (FDA). Center for Devices and Radiological Health. NeuroMetrix NC-stat. 510(k) summary. [FDA Web site]. 07/31/06. Available at: http://www.accessdata.fda.gov/cdrh_docs/pdf6/K060584.pdf. Accessed September 19, 2023.

Coding

CPT Procedure Code Number(s)

MEDICALLY NECESSARY

95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95925, 95926, 95927, 95928, 95929, 95937, 95938, 95939

THE FOLLOWING CODES REPRESENT H REFLEX STUDIES:

95907, 95908, 95909, 95910, 95911, 95912, 95913

EXPERIMENTAL/INVESTIGATIONAL

0106T, 0107T, 0108T, 0109T, 0110T

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

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

HCPCS Level II Code Number(s)

EXPERIMENTAL/INVESTIGATIONAL

G0255 Current perception threshold/sensory nerve conduction threshold (sNCT) test, per limb, any nerve

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 07.03.18t:

10/18/2023	The policy has been reviewed and reissued to communicate the Company's continuing position on Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies.
10/1/2023	This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2023. The following ICD-10 Diagnosis codes have been added to Attachment B of this policy: G20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations G20.A2 Parkinson's disease without dyskinesia, with fluctuations G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations G20.B2 Parkinson's disease with dyskinesia, with fluctuations G20.C Parkinsonism, unspecified G37.81 Myelin oligodendrocyte glycoprotein antibody disease G37.89 Other specified demyelinating diseases of central nervous system The following ICD-10 Diagnosis codes has been termed from Attachment B of this policy: G20 Parkinson's Disease G37.8 Other specified demyelinating disease of central nervous system

10/18/2023

The policy has been reviewed and reissued to communicate the Company's continuing position on Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies.

10/1/2023

This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2023.

The following ICD-10 Diagnosis codes have been added to Attachment B of this policy:

G20.A1 Parkinson's disease without dyskinesia, without mention of fluctuations

G20.A2 Parkinson's disease without dyskinesia, with fluctuations

G20.B1 Parkinson's disease with dyskinesia, without mention of fluctuations

G20.B2 Parkinson's disease with dyskinesia, with fluctuations

G20.C Parkinsonism, unspecified

G37.81 Myelin oligodendrocyte glycoprotein antibody disease

G37.89 Other specified demyelinating diseases of central nervous system

The following ICD-10 Diagnosis codes has been termed from Attachment B of this policy:

G20 Parkinson's Disease

G37.8 Other specified demyelinating disease of central nervous system

Revisions From 07.03.18s:

11/16/2022

The policy has been reviewed and reissued to Communicate the Company's continued position on Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies.

10/01/2022

This policy has been identified for the ICD-10 Diagnosis code update, effective 10/01/2022.

The following ICD-10 Diagnosis codes have been added to Attachment C of this policy: G71.031, G71.032, G71.033, G71.0340, G71.0341, G71.0342, G71.0349, G71.035, G71.038, G71.039, G93.31, G93.32, G93.39

The following ICD-10 Diagnosis code has been removed from Attachment C of this policy: G93.3

The following ICD-10 Diagnosis codes have been added to Attachment E of this policy: M62.5A0, M62.5A1, M62.5A2, M62.5A9

Revisions From 07.03.18r:

03/21/2022

This version of the policy will become effective 03/21/2022.

Policy language was added to indicate that for the sole purpose of diagnosing or confirming radiculopathy, nerve conduction studies (NCS) when not conducted and interpreted at the same time as a needle electromyography (EMG) will be considered Not Medically Necessary and, therefore, not covered.

Revisions From 07.03.18q:

10/01/2021

This policy has been identified for the ICD-10 code update, effective 10/01/2021.

The following ICD-10 Diagnosis code has been revised in Attachment C of this policy: G71.20

The following ICD-10 Diagnosis code has been removed from Attachment E of this policy: M54.5

The following ICD-10 Diagnosis codes have been added to Attachment E of this policy: M54.50, M54.51, M54.59

Revisions From 07.03.18p:

12/16/2020

This policy has been reissued in accordance with the Company's annual review process.

10/01/2020

This policy has been identified for the ICD-10 code update, effective 10/01/2020.

The following ICD-10 Diagnosis code has been removed from Attachment B of this policy: G11.1

The following ICD-10 Diagnosis codes have been added to Attachment B of this policy as Medically Necessary: G11.10, G11.11, G11.19

The following ICD-10 Diagnosis code has been removed from Attachment C of this policy: G71.2

The following ICD-10 Diagnosis codes have been added to Attachment C of this policy as Medically Necessary: G71.20, G71.21, G71.220, G71.228, G71.29

Revisions From 07.03.18o:

11/20/2019	This policy has been reissued in accordance with the Company's annual review process.
10/01/2019	This 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 07.03.18n:

10/01/2018

This 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 07.03.18m:

07/23/2018

This 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:

10/1/2023

Version Issued Date:

9/29/2023

Version Reissued Date:

10/18/2023

07.03.18

Medical Policy Bulletin

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