Electromyography and Nerve Conduction Studies (Electrodiagnostic Assessment)
DESCRIPTION
Electromyography (EMG) and nerve conduction studies (NCS), collectively known as electrodiagnostic (EDX) assessment, are intended to evaluate the electrical functioning of muscles and peripheral nerves. These tests are used as diagnostic aids for the evaluation of myopathy and peripheral neuropathy by identifying, localizing, and characterizing electrical abnormalities in the skeletal muscles and peripheral nerves. These tests are performed when there is a clinical suspicion for a myopathic or neuropathic process and when clinical examination and standard laboratory testing are unable to make a definitive diagnosis. The results of these tests do not generally provide a specific diagnosis; however, they provide additional information that assists the physician in characterizing a clinical syndrome.
Nerve conduction studies performed without needle EMG may be missing valuable data that could be essential to determine an accurate diagnosis. Dissociation of nerve conduction studies (NCS) and the EMG into separate reports are generally inappropriate, however there are exceptions.
POLICY
Electromyography (EMG) and nerve conduction studies (NCS) are considered medically necessary for the following indications:
Focal neuropathies, entrapment neuropathies, compressive lesions/syndromes such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization
Traumatic nerve lesions, for diagnosis and prognosis
Generalized neuropathies, such as diabetic, uremic, metabolic, toxic, hereditary or immune-mediated
Neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome or botulism
Symptom-based presentations such as “pain in limb”, weakness, disturbance of skin sensation or paraesthesia when appropriate pre-test evaluations are inconclusive
Radiculopathies (e.g., cervical, lumbosacral, thoracic)
Plexopathies (e.g., idiopathic, traumatic, inflammatory, infiltrative, radiation-induced)
Myopathies (e.g., polymyositis and dermatomyositis, myotonic disorders, and congenital myopathies)
Precise muscle location for injections such as botulinum toxin, phenol
Nerve conduction studies, when performed alone, maybe considered medically necessary if ANY ONE of the following are met:
Individual has a contraindication to the use of needle electromyography (EMG) (e.g., on anticoagulant therapy, hemophilia, Von Willebrand’s disease, idiopathic thrombocytopenic purpura [ITP], disseminated intravascular coagulation [DIC])
Carpal tunnel syndrome (unilateral, bilateral)
Nerve conduction studies performed without needle electromyography (EMG) for all other uses is considered investigational.
Automated (e.g., pre-configured) nerve conduction testing (e.g., NC-stat®, ADVANCE™, DPNCheck™) is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g., statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
It is the position of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) that electrodiagnostic (EDX) evaluations must be performed by physicians who have comprehensive knowledge of neurological and musculoskeletal disorders to assure accurate interpretation and diagnosis, and to provide individuals with quality care. The typical EDX evaluation involves: a focused neuromuscular history and physical examination, the development of a differential diagnosis, the examination of muscles and nerves utilizing nerve conduction studies and needle electromyography, and the determination of a final diagnosis. The standard of care in clinical practice dictates that each of these components cannot be predetermined or standardized. Once the preliminary differential diagnosis has been determined, a technician may perform the nerve conduction studies (NCS) that were selected by the physician.
BCBST concurs with the position of AANEM that the physician performing EDX has received special training in the diagnosis and treatment of neurological and neuromuscular diseases and in the application of particular neurophysiologic techniques to the study of these disorders. This type of training is generally included in the residency or fellowship programs of physicians who specialize in physical medicine and rehabilitation (physiatrists) or neurology (neurologists). This specialized training is comprehensive including presentation of didactic materials by an experienced EDX consultant, a lengthy preceptorship under the supervision of an experienced EDX consultant, and the completion of a specified number of EDX evaluations (generally 200 or more). BCBST does not recognize 2-to-3-day training courses (e.g. Vendor/manufacturer/distributor provided training, device specific training, week-end workshops, DVD training) as meeting the standards for specialized training in the field of EDX.
The technician performing NCS under the physician’s supervision, must be trained in electrodiagnostic testing and licensed or certified by the state (or by one of the state's health related boards if licensure or certification as a technician does not exist in a given state) in which the studies are performed.
Published scientific evidence in peer-reviewed journals regarding the utilization of automated, non-invasive nerve conduction equipment for diagnosis of disease of the peripheral nervous system is lacking.
SOURCES
American Association of Electrodiagnostic Medicine. (2003, January). Consensus criteria for the diagnosis of multifocal motor neuropathy. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/afd29b39-2179-421e-bac7-f88b4294a27d/CCDiagoseMMN.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2011, October). Electrodiagnostic Evaluation of Carpal Tunnel Syndrome. Retrieved April 21, 2022 from http://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2015). Mobile electrodiagnostic laboratories provide substandard patient care. Retrieved September 14, 2016 from https://www.aanem.org/clinical-practice-resources/position-statements.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2024, April). Who is qualified to practice electrodiagnostic medicine? Retrieved August 29, 2024 from http://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2020, December). Common indicators suggesting fraud & abuse in electrodiagnostic medicine. Retrieved June 8, 2021 from https://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2020). Proper performance and interpretation of electrodiagnostic studies. Retrieved June 8, 2021 from https://www.aanem.org/clinical-practice-resources/position-statements.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2020, January). Referral indications for primary care providers. Retrieved August 1, 2023 from https://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2022, December). Model policy for nerve conduction studies and needle electromyography. Retrieved August 1, 2023 from https://www.aanem.org/clinical-practice-resources/position-statements.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2023, January). Recommended policy for electrodiagnostic medicine. Retrieved August 1, 2023 from https://www.aanem.org/clinical-practice-resources/position-statements.
BlueCross BlueShield Association. Evidence Positioning System. (7:2024). Electromyography and nerve conduction studies. (2.01.95). Retrieved August 28, 2024 from www.bcbsaoca.com/eps/. (18 articles and/or guidelines reviewed)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2023, November). Nerve Conduction Studies and Electromyography. (LCD ID L35048). Retrieved August 28, 2024 from https://www.cms.gov.
Grigoriu, A.I., Dinomais, M., Rémy-Néris, O., & Brochard, S. (2015). Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: a systematic review. Archives of Physical Medicine and Rehabilitation, 96 (11), 2067-2078. (Level 1 evidence)
Ploumis, A., Varvarousis, D., Konitsiotis, S., & Beris, A. (2014). Effectiveness of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity in hemiplegic patients: a randomized controlled trial. Disability and Rehabilitation, 36 (4), 313-318. Abstract retrieved September 15, 2016 from PubMed database.
U. S. Food and Drug Administration. (2003, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K070109. Retrieved September 21, 2010 from http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2003, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K060584. Retrieved September 21, 2010 from: http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2011, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K102610. Retrieved March 13. 2014 from http://www.accessdata.fda.gov.
Wu, C., Xue, F., Chang, W., Lian, Y., Zheng, Y., Xie,N., et al. (2016). Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia. SpringerPlus, 5, 1292. DOI 10.1186/s40064-016-2967-x. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 4/1981
MOST RECENT REVIEW DATE: 10/10/2024
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