517 Form

1

Medical Policy Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 517

BCBSA Reference Number: 2.01.35 (For Plan internal use only) NCD/LCD: N/A

Related Policies
None

Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members

Paraspinal surface electromyography is INVESTIGATIONAL as a technique to diagnose or monitor back pain.

Prior Authorization Information Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service.

CPT Codes / HCPCS Codes / ICD Codes Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

2

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

CPT Codes There is no specific CPT code for this service.

HCPCS Codes HCPCS codes: Code Description S3900 Surface electromyography (SEMG)

Description Back Pain Back pain is a common condition that affects most individuals at some point in their lives.1, Identifying the pathogenesis of back pain is challenging, in part due to the complex anatomy of the back, which includes vertebrae, intervertebral discs, facet joints, spinal nerve roots, and numerous muscles. Back pain may be related to osteoarthritis, disc disease, subluxation, or muscular pathologies, such as muscle strain or spasm. Moreover, due to referred pain patterns, the location of the pain may not be anatomically related to the pathogenesis of the pain. For example, buttock or leg pain may be related to pathology in the spine. In addition to the diagnostic challenges of back pain is the natural history of acute back pain.

Diagnosis Aside from physical examination, diagnostic testing includes imaging technologies, such as magnetic resonance imaging, designed to identify pathology (eg, bulging discs), or tests such as discography to localize the abnormality by reproducing the pain syndrome.1, However, these tests lack specificity and must be carefully interpreted in the context of the clinical picture. For example, magnetic resonance imaging identifies 5% of asymptomatic patients as having bulging discs. However, the presence of a bulging disc may only be clinically significant if correlated with other symptoms. Assessment of the musculature may focus on a range of motion or strength exercises.

In contrast to anatomic imaging, surface electromyography (SEMG), which records the summation of muscle activity from groups of muscles, has been investigated as a technique to evaluate the physiologic functioning of the back.2, A noninvasive procedure, SEMG differs from needle electromyography, an invasive procedure in which the electrical activity of individual muscles is recorded. Paraspinal SEMG has been explored to evaluate abnormal patterns of electrical activity in the paraspinal muscles in patients with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders. The technique is performed using a single or an array of electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises. Recordings can also be made by using a handheld device, which is applied to the skin at different sites. Electrical activity is assessed by computer analysis of the frequency spectrum (ie, spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, a spectral analysis that focuses on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises. Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and has been used to monitor the response to therapy and establish physical activity limits, such as assessing capacity to lift heavy objects or ability to return to work.

Paraspinal SEMG is an office-based procedure. The following clinical applications of the paraspinal SEMG have been proposed: • clarification of diagnosis (ie, muscle, joint, or disc disease) • selection of a course of medical therapy • selection of a type of physical therapy • preoperative evaluation • postoperative rehabilitation • follow-up of acute low back pain (LBP) • evaluation of exacerbation of chronic LBP

3

• evaluation of pain management treatment techniques.

Treatment Most cases of acute LBP resolve with conservative therapy (eg, physical therapy) while continuing normal activities within limits permitted by the pain.1, Therefore, initial imaging or other diagnostic testing is generally not recommended unless "red flag" warning signs are present or the pain persists for more than 4 to 6 weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.

Summary Description A noninvasive procedure that records the summation of muscle electrical activity, paraspinal surface electromyography (SEMG) has been investigated as a technique to evaluate the physiologic functioning of the back. Additionally, this procedure has been studied as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in individuals with back pain symptoms, such as spasm, tenderness, limited range of motion, or postural disorders.

Summary of Evidence For individuals who have back pain who receive paraspinal surface electromyography (SEMG) for evaluation and monitoring, the evidence includes several nonrandomized studies on using findings to classify back pain. Relevant outcomes are test accuracy and validity, symptoms, functional outcomes, quality of life, and resource utilization. There have been no studies directly comparing SEMG with other noninvasive techniques for evaluating back pain, and standard criteria for normal and abnormal SEMG measurements have not been determined. Surface electromyography has been proposed as a noninvasive technique providing objective measurements that would inform treatment decisions in patients with back pain. While studies have shown that SEMG results have detected different pathologies in patients with back pain, none of the studies reported health outcomes. There are also no data on the impact of SEMG for managing back pain. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 8/2025 Annual policy review. Policy updated with literature review through April 18, 2025; no references added. Policy statement unchanged. 8/2024 Annual policy review. Policy updated with literature review through April 10, 2024; no references added. Policy statement unchanged. 8/2023 Annual policy review. References added. Policy statement unchanged. 8/2022 Annual policy review. Description and summary updated. Policy statements unchanged. 12/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 8/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2018 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 7/2017 Annual policy review. New references added. 11/2015 Annual policy review. New references added. 12/2013 Annual policy review. New references added. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements. 6/2011 Medical Policy Group - Orthopedics, Rehabilitation and Rheumatology. No changes to policy statements. 2/1/2010 Medical Policy 517 created.

4

Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Knezevic NN, Candido KD, Vlaeyen JWS, et al. Low back pain. Lancet. Jul 03 2021; 398(10294): 78-
2. PMID 34115979
3. Hegmann KT, Travis R, Belcourt RM, et al. Diagnostic Tests for Low Back Disorders. J Occup Environ Med. Apr 2019; 61(4): e155-e168. PMID 30694882
4. Cram JR, Lloyd J, Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom. 1994; 41(1-4): 41-5. PMID 7843866
5. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve. Feb 1993; 16(2): 210-6. PMID 8429847
6. 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. Sep 2012; 221(4): 413-26. PMID 22875027
7. 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). Apr 15 2012; 37(8): E486-95. PMID 22024899
8. 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. Oct 2011; 3(10): 920-8. PMID 22024323
9. 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. Apr 2013; 29(4): 334-40. PMID 23328325
10. du Rose A, Breen A. Relationships between Paraspinal Muscle Activity and Lumbar Inter-Vertebral Range of Motion. Healthcare (Basel). Jan 05 2016; 4(1). PMID 27417592
11. Hu Y, Siu SH, Mak JN, et al. Lumbar muscle electromyographic dynamic topography during flexion- extension. J Electromyogr Kinesiol. Apr 2010; 20(2): 246-55. PMID 19540776
12. 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. Jun 01 2014; 14(6): 1049-56. PMID 24530438
13. 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. Annu Int Conf IEEE Eng Med Biol Soc. 2014; 2014: 18-21. PMID 25569886
14. 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. Mar 2005; 14(2): 175-84. PMID 15549487
15. Peach JP, McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine (Phila Pa 1976). May 15 1998; 23(10): 1117-23. PMID 9615362
16. Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther. Aug 1998; 78(8): 838-51. PMID 9711209
17. 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. Dec 2014; 24(6): 954-64. PMID 25304196
18. Kienbacher T, Fehrmann E, Habenicht R, et al. Age and gender related neuromuscular pattern during trunk flexion-extension in chronic low back pain patients. J Neuroeng Rehabil. Feb 19 2016; 13: 16. PMID 26896325
19. Schabrun SM, Elgueta-Cancino EL, Hodges PW. Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain. Spine (Phila Pa 1976). Aug 01 2017; 42(15): 1172-1178. PMID 25893342

5

19. 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. Aug 1988; 88(8): 991-7. PMID 2975645
20. Bittman B, Cram JR. Surface electromyography: an electrophysiological alternative in pain management. Paper presented at: Presented at the American Pain Society; Oct 22-25 1992; San Diego, CA.
21. Kreiner DS, Matz P, Bono CM, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. Jul 2020; 20(7): 998-1024. PMID 32333996