Anthem Blue Cross Connecticut CG-MED-24 Electromyography and Nerve Conduction Studies Form

This document addresses the use of electromyography (EMG) and nerve conduction studies (NCS) in the outpatient setting. Needle EMG and NCS typically comprise the electrodiagnostic evaluation of function of the motor neurons, nerve roots, peripheral nerves, neuromuscular junction and skeletal muscles. This document also addresses neuromuscular junction testing regardless of place of service.

Note: For information about other related topics, see:

• CG-MED-50 Visual, Somatosensory and Motor Evoked Potentials
• CG-SURG-112 Carpal Tunnel Decompression Surgery
• MED.00082 Quantitative Sensory Testing
• MED.00092 Automated Nerve Conduction Testing

Clinical Indications

Medically Necessary:

1. Needle EMG when performed with NCS at the same time of testing are considered medically necessary for diagnosing neuropathy with sensory loss, weakness or muscle atrophy for any of the following indications (1 thru 5):
   1. Unexplained peripheral neuropathy with pain of a neuropathic pattern, demonstrated sensory loss, or motor loss on physical examination; or
   2. Neuropathy suspected to be due to trauma; or
   3. When test results are expected to guide the management of conditions known to cause neuropathy, including but not limited to (a thru d):
      1. HIV-positive individuals with symptoms of neuropathy; or
      2. Mononeuropathies, such as Bell’s palsy of the facial nerve; or
      3. Diabetics with persistent or progressive symptoms refractory to conventional treatments; or
      4. Individuals on dialysis or those considering dialysis; or
   4. Suspected neural impingement or entrapment where symptoms are persistent or unresponsive to initial conservative treatments, as indicated by any of the following (a thru g):
      1. Carpal tunnel syndrome (when clinical documentation shows impingement symptoms refractory to activity modification and at least 4 weeks of wrist splint use)*; or
      2. Ulnar neuropathy at the elbow or wrist (when clinical documentation shows impingement symptoms refractory to activity modification and at least 4 weeks of elbow pad use)*; or
      3. Cervical or lumbar radiculopathy (when clinical documentation shows 4-6 weeks of failed conservative therapy, including physical therapy and where the etiology of the radicular symptoms is not explained by MRI or other diagnostic studies); or
      4. Tarsal tunnel syndrome (when clinical documentation shows pain and numbness isolated to the foot); or
      5. Peroneal palsy with foot drop; or
      6. Suspected brachial or lumbosacral plexus impingement; or
      7. Other peripheral nerve entrapment syndromes; or
   5. Significant clinical suspicion for any of the following conditions (a thru g):
      1. Amyotrophic lateral sclerosis; or
      2. Guillain-Barre syndrome; or
      3. Hereditary myopathies, (for example, muscular dystrophy); or
      4. Hereditary neuropathies, (for example, Charcot-Marie-Tooth disease); or
      5. Inflammatory myopathies, (for example, polymyositis, chronic inflammatory demyelinating polyneuropathy [CIDP]); or
      6. Inflammatory or idiopathic brachial or lumbosacral plexopathy; or
      7. Post-polio syndrome.

*Note: In cases of carpal tunnel syndrome or ulnar neuropathy, the requirement for a period of conservative treatment may be waived if the physical exam demonstrates significant atrophy or weakness or sensory loss.

2. Needle EMG when performed with NCS at the same time of testing are considered medically necessary for diagnosis of individuals with significant clinical suspicion for any of the following neuromuscular junction diseases (1 thru 3):
   1. Myasthenia gravis; or
   2. Eaton-Lambert syndrome; or
   3. Botulism.
3. NCS performed without needle EMG at the same time of testing is considered medically necessary for any of the following clinical indications (1 thru 7):
   1. Evaluation of suspected carpal or tarsal tunnel syndrome; or
   2. Evaluation of suspected acute nerve injury (that is within 3 weeks of occurrence); or
   3. For individuals on anticoagulant therapy (not merely anti-platelet treatments); or
   4. For individuals with significant lymphedema; or
   5. Evaluation of suspected peroneal palsy; or
   6. Evaluation of thoracic outlet syndrome; or
   7. For facial nerve monitoring in Bells palsy.
4. Needle EMG performed without NCS at the same time of testing is considered medically necessary for the evaluation of suspected radiculopathy.

Not Medically Necessary: 

Needle EMG performed with NCS at the same time of testing are considered not medically necessary when the criteria listed above are not met, including as a screening tool for the general population, in the absence of related symptoms.

NCS performed without needle EMG at the same time of testing is considered not medically necessary except the limited clinical indications listed above.

Needle EMG performed without NCS at the same time of testing is considered not medically necessary when the criteria listed above are not met.

Testing for neuromuscular junction diseases with needle EMG or NCS is considered not medically necessary when the criteria above are not met, and for all other indications.

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