Automated Point–of-Care Nerve Conduction Tests Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 09|01|2016 POLICY LAST REVIEWED: 06|18|2025

OVERVIEW Portable devices have been developed to provide point-of-care nerve conduction studies (NCSs). These devices have computational algorithms that are able to drive stimulus delivery, measure and analyze the response, and provide a report of study results. Automated nerve conduction could be used in various settings, including primary care, without the need for specialized training or equipment.

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Not applicable

POLICY STATEMENT Medicare Advantage Plans Automated point-of-care nerve conduction studies (portable hand-held devices like the NC-stat® and Brevio) are considered covered and medically necessary.

The Sensory Nerve Conduction Threshold Test (sNCT) test and the device is not covered as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

Note: Blue Cross & Blue Shield of Rhode Island (BCBSRI) must follow Centers for Medicare and Medicaid Services (CMS) guidelines, such as national coverage determinations or local coverage determinations for all Medicare Advantage Plans policies. Therefore, Medicare Advantage Plans policies may differ from Commercial products. In some instances, benefits for Medicare Advantage Plans may be greater than what is allowed by the CMS.

Commercial Products Automated point-of-care nerve conduction studies (portable hand-held devices like the NC-stat and Brevio) are considered not medically necessary as the evidence is insufficient to determine that the technology results in an improvement in the net health outcomes.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Evidence of Coverage or Subscriber Agreement for applicable diagnostic imaging, lab, and machine tests benefits.

BACKGROUND Nerve conduction studies and needle electromyography (EMG), when properly performed by a trained practitioner, are considered the criterion standard of electrodiagnostic testing. However, the need for specialized equipment and personnel may limit the availability of electrodiagnostic testing for some patients.

For individuals who have entrapment carpal tunnel syndrome who received automated POC NCSs, the evidence includes studies on the diagnostic accuracy and clinical outcomes from industry-sponsored trials, nonrandomized trials, and registry data. Relevant outcomes are test accuracy and validity, symptoms, and functional outcomes. Four RCTs have reported on the diagnostic accuracy of automated POC nerve conduction testing to diagnose carpal tunnel syndrome. Sensitivity testing has suggested there could be diagnostic value in detecting carpal tunnel syndrome; specificity testing was inconsistent across trials. No Medical Coverage Policy |Automated Point–of-Care Nerve Conduction Tests

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

reference ranges were validated, and normative values were not defined in these studies. No validation testing by trained medical assistants vs trained specialist was reported in the studies. The evidence on clinical outcomes is limited to a single nonrandomized clinical trial and NeuroMetrix registry data. Neither reported health outcomes assessing patient symptoms or changes in functional status. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with lumbosacral radiculopathy who received automated POC NCSs, the evidence includes industry-sponsored trials and a nonrandomized study of diagnostic accuracy. Relevant outcomes are test accuracy and validity, symptoms, and functional outcomes. The evidence on the diagnostic accuracy of POC NCS in this population has shown variable test results across reported trials. No normative values were defined. Weaknesses of the studies included lack of applicable or valid reference ranges for testing, and variable test results validating or confirming pathology. The results of the 2 studies on diagnostic performance were inconclusive, with high false-positive results in a single trial. No trials on health outcomes assessing patient symptoms or changes in functional status were identified. The evidence is insufficient to determine the effects of the technology on health outcomes.

For individuals with diabetic peripheral neuropathy who received automated POC NCSs, the evidence includes industry sponsored observational trials and nonrandomized studies on the diagnostic accuracy. Relevant outcomes are test accuracy and validity, symptoms, and functional outcomes. Of 3 studies reporting evidence on diagnostic accuracy, 2 used NC-stat DPNCheck. Sensitivity testing has suggested there could be diagnostic value in detecting diabetic peripheral neuropathy in symptomatic patients; the evidence to detect patients who are suspected of disease but who have mild symptoms was inconsistent. No reference ranges were validated, and normative values were not defined in 2 of the 3 studies. No validation testing by trained medical assistants vs trained specialist was reported in the studies. No trials on health outcomes assessing patient symptoms or changes in functional status were identified. The evidence is insufficient to determine the effects of the technology on health outcomes.

Medicare Advantage Plans
Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT) – is not covered by Medicare. This procedure is different and distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different from short-latency somatosensory evoked potentials. Codes designated for eliciting nerve conduction velocity, latency or amplitude, and those designed for short latency evoked potentials are not to be used for sNCT. The sNCT has a unique code G0255: Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore, sNCT was noncovered. Based on a reconsideration [in March, 2004] of current Medicare policy for sNCT, CMS concludes that there continues to be insufficient scientific or clinical evidence to consider the sNCT test and the device used in performing this test as reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law.

CODING Medicare Advantage Plans
The following code(s) is medically necessary for Medicare Advantage Plans: 95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and
latency/velocity study, each limb, includes F-wave study when performed, with interpretation and
report

The following code is not covered for Medicare Advantage Plans:
G0255 Current perception threshold/sensory nerve conduction test, (SNCT) per limb, any nerve Commercial Products
The following code(s) are not medically necessary for Commercial Products:
95905 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and
latency/velocity study, each limb, includes F-wave study when performed, with interpretation and
report G0255 Current perception threshold/sensory nerve conduction test, (SNCT) per limb, any nerve

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

RELATED POLICIES Not applicable

PUBLISHED Provider Update, August 2025 Provider Update, January/October 2024 Provider Update, December 2022 Provider Update, December 2021 Provider Update, December 2020

REFERENCES

1. CMS Publication 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 160.23
2. Centers for Medicare and Medicaid Services (CMS). Local Coverage Determination (LCD): Nerve Conduction Studies and Electromyography (L35098)
3. Centers for Medicare and Medicaid Services (CMS). Local Coverage Article: Billing and Coding: Nerve Conduction Studies and Electromyography (A57668)
4. MacDermid JC, Doherty T. Clinical and electrodiagnostic testing of carpal tunnel syndrome: a narrative review. J Orthop Sports Phys Ther. Oct 2004;34(10):565-588. PMID 15552704
5. Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American Diabetes Association. Diabetes Care. Apr 2005;28(4):956-962. PMID 15793206
6. Kong X, Lesser EA, Gozani SN. Repeatability of nerve conduction measurements derived entirely by computer methods. Biomed Eng Online. Nov 06 2009;8:33. PMID 19895683
7. Dillingham T, Chen S, Andary M, et al. Establishing high-quality reference values for nerve conduction studies: A report from the normative data task force of the American Association of Neuromuscular & Electrodiagnostic Medicine. Muscle Nerve. Sep 2016;54(3):366-370. PMID 27238858
8. American Academy of Neurology (AAN). Policy & Guidelines: Endorsed or Affirmed Guidelines. n.d.; https://www.aan.com/Guidelines/Home/ByStatusOrType?status=affirmed. Accessed May 18, 2018.
9. Chen S, Andary M, Buschbacher R, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve. Sep 2016;54(3):371-377. PMID 27238640
10. Leffler CT, Gozani SN, Cros D. Median neuropathy at the wrist: diagnostic utility of clinical findings and an automated electrodiagnostic device. J Occup Environ Med. Apr 2000;42(4):398-409. PMID 10774509
11. Rotman MB, Enkvetchakul BV, Megerian JT, et al. Time course and predictors of median nerve conduction after carpal tunnel release. J Hand Surg Am. May 2004;29(3):367-372. PMID 15140473
12. Katz RT. NC-stat as a screening tool for carpal tunnel syndrome in industrial workers. J Occup Environ Med. Apr 2006;48(4):414-418. PMID 16607197
13. Armstrong TN, Dale AM, Al-Lozi MT, et al. Median and ulnar nerve conduction studies at the wrist: criterion validity of the NC-stat automated device. J Occup Environ Med. Jul 2008;50(7):758-764. PMID 18617831
14. Bourke HE, Read J, Kampa R, et al. Clinic-based nerve conduction studies reduce time to surgery and are cost effective: a comparison with formal electrophysiological testing. Ann R Coll Surg Engl. Apr 2011;93(3):236-240. PMID 21477439
15. Megerian JT, Kong X, Gozani SN. Utility of nerve conduction studies for carpal tunnel syndrome by family medicine, primary care, and internal medicine physicians. J Am Board Fam Med. Jan-Feb 2007;20(1):60-64. PMID 17204736
16. Fisher MA, Bajwa R, Somashekar KN. Routine electrodiagnosis and a multiparameter technique in lumbosacral radiculopathies. Acta Neurol Scand. Aug 2008;118(2):99-105. PMID 18355396
17. Schmidt K, Chinea NM, Sorenson EJ, et al. Accuracy of diagnoses delivered by an automated hand-held nerve conduction device in comparison to standard electrophysiological testing in patients with unilateral leg symptoms. Muscle Nerve. Jan 2011;43(1):9-13. PMID 21108323
18. England JD, Franklin GM. Automated hand-held nerve conduction devices: raw data, raw interpretations [editorial]. Muscle Nerve. Jan 2011;43(1):6-8. PMID 21171092
19. Perkins BA, Grewal J, Ng E, et al. Validation of a novel point-of-care nerve conduction device for the detection of diabetic sensorimotor polyneuropathy. Diabetes Care. Sep 2006;29(9):2023-2027. PMID 16936147

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

20. Sharma S, Vas PR, Rayman G. Assessment of diabetic neuropathy using a point-of-care nerve conduction device shows significant associations with the LDIFLARE method and clinical neuropathy scoring. J Diabetes Sci Technol. Jan 2015;9(1):123-131. PMID 25231114
21. Chatzikosma G, Pafili K, Demetriou M, et al. Evaluation of sural nerve automated nerve conduction study in the diagnosis of peripheral neuropathy in patients with type 2 diabetes mellitus. Arch Med Sci. Apr 01 2016;12(2):390-393. PMID 27186185
22. Young MJ, Boulton AJ, MacLeod AF, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia. Feb 1993;36(2):150-154. PMID 8458529
23. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Proper Performance and Interpretation of Electrodiagnostic Studies. 2014 https://www.aanem.org/getmedia/bd1642ce-ec01- 4271-8097- 81e6e5752042/PositionStatementProper-Performance-of-EDX-2014.pdf.aspx. Accessed July 25, 2020.

24. American Academy of Orthopaedic Surgeons. Management of Carpal Tunnel Syndrome Evidence-Based Clinical Practice Guideline. 2016; https://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/CTS %20CPG_2.29.16.pdf. Accessed July 24, 2020.

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    This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS