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393

Indications

(1) Individual presents with symptoms of painful sensory neuropathy; AND 2. There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); AND 3. Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation; AND 4. Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy. Skin biopsy with epidermal nerve fiber density measurement is considered INVESTIGATIONAL for all other conditions, including, but not limited to, the monitoring of disease progression or response to treatment. Measurement of sweat gland nerve fiber density is INVESTIGATIONAL. 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. 2 Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. 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. 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. Description Peripheral Neuropathy Most patients with peripheral neuropathy exhibit evidence of large fiber involvement, characterized by numbness, tingling, loss of deep tendon reflexes, and abnormal electrophysiologic studies. In contrast, damage to small fibers is not detected by routine nerve conduction studies. Patients with small fiber neuropathy, involving myelinated A delta and unmyelinated C fibers, may complain of severe pain and exhibit diminished thermal and pain perception. The pain, which is frequently reported in the feet, is described as burning, prickling, stabbing, jabbing, or tight band-like pressure. If there is involvement of autonomic C fibers, symptoms such as coldness, discoloration, and hyper- or hypohidrosis may be present. Small fiber neuropathy occurs most often in patients with diabetic neuropathy but may also be found in patients with impaired glucose tolerance, severe hypertriglyceridemia, metabolic syndrome, HIV infection, and toxic neuropathy from antiretroviral drugs. For many patients, no specific etiology is identified. Diagnosis Small fiber neuropathy is diagnosed clinically but has traditionally been a diagnosis of exclusion based on clinical findings and the absence of large fiber involvement, as determined by electrophysiologic studies. The disparity between subjective complaints and objective signs increases the difficulty of diagnosis. Also, conditions other than nerve fiber damage, including venous insufficiency, spinal stenosis, myelopathy, and psychosomatic disturbances, may mimic small fiber neuropathy. Skin Biopsy Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve fibers using antibodies to a marker found in peripheral nerves. A specific test to assess intraepidermal nerve fiber (IENF) density and sweat gland nerve fiber density using skin biopsy and immunostaining of the tissue have been developed that allow the identification and counting of intraepidermal and sudomotor nerve fibers. Assessment of nerve fiber density typically involves a 3-mm punch biopsy of skin from the calf (and sometimes foot or thigh). After sectioning by microtome, the tissue is immunostained with anti-protein-gene-product 9.5 antibodies and examined with immunohistochemical or immunofluorescent methods. This technique has improved research and contributed greatly to the understanding of small fiber neuropathy. Skin biopsy with measurement of IENF density has also been investigated as an objective measure for the diagnosis of small fiber neuropathy. Sweat gland nerve fiber density can be assessed from the same tissue prepared for IENF density testing provided that the biopsy sample is of sufficient depth. Tissue samples may also be counterstained to identify the boundaries of the sweat glands better. 3 Treatment There is no curative treatment for small fiber peripheral neuropathy. Medications may be provided for pain management, and for some etiologies, treatment of the underlying condition (eg, glucose control, intravenous immunoglobulin, or plasma exchange) may be given to reduce the progression of the disease and its symptoms. Summary Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve fibers using antibodies to a marker found in peripheral nerves. This procedure is proposed as an objective measure of small fiber neuropathy by identifying a reduction in the density of nerve fibers. Summary of Evidence For individuals with suspected idiopathic small fiber neuropathy who receive intraepidermal nerve fiber (IENF) density measurement, the evidence includes reports assessing whether IENF density measurement is technically reliable, clinically valid, and clinically useful. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. Techniques to measure IENF density have led to an improved understanding of the relation between the loss of small nerve fibers and symptoms of peripheral neuropathy. The literature has also indicated that low IENF density may provide supportive evidence of a lesion in the peripheral somatosensory system. For example, there is a significant decrease in average IENF density in patients diagnosed with small fiber neuropathy compared with controls, and an IENF density of 4 to 8 per mm in the calf is near the fifth percentile of normal values, suggesting an increased probability of small fiber neuropathy below these cutoffs. For individuals who have symptoms suggestive of neuropathy but no evidence of large nerve neuropathy and no disease associated with neuropathy (eg, diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy), establishing a cause for the symptoms is problematic. Thus, IENF density measurement may help to diagnose idiopathic small fiber neuropathy in those who have no evidence of large fiber neuropathy and no known cause of neuropathy. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have an established diagnosis of small fiber neuropathy who receive repeated IENF density measurement, the evidence is limited. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. A number of trials are ongoing or have recently been completed; they assess the efficacy of activity and medications on small fiber neuropathy. If successful, there might be a role for repeated IENF density measurements to result in a change in management (eg, changing dose or class of medication). However, current treatments for small fiber neuropathy only palliate symptoms and do not modify the underlying changes in nerve fiber density in patients with symptomatic neuropathy. There is no evidence that monitoring the progression of neuropathy has clinical utility. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have suspected small fiber neuropathy who receive sweat gland nerve fiber density measurement, the evidence includes comparisons with control values. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. Measurement of sweat gland nerve fiber density may lead to an improved understanding of the relation between the loss of sudomotor nerve fibers and symptoms of peripheral neuropathy. However, no studies were identified that evaluated the diagnostic accuracy of sweat gland nerve fiber density measurement. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 2/2025 Annual policy review. References updated. Policy statements unchanged. 1/2024 Annual policy review. References updated. Policy statements unchanged. 4 2/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2017 Annual policy review. New investigational indications described. Title changed. Effective 5/1/2017. 12/2014 Annual policy review. New references added. 1/2014 Annual policy review. New references added. 11/1/12 New policy describing ongoing coverage and non-coverage. 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. England JD, Gronseth GS, Franklin G, et al. Practice Parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. Jan 13 2009; 72(2): 177-84. PMID 19056667 2. McArthur JC, Stocks EA, Hauer P, et al. Epidermal nerve fiber density: normative reference range and diagnostic efficiency. Arch Neurol. Dec 1998; 55(12): 1513-20. PMID 9865794 3. Holland NR, Stocks A, Hauer P, et al. Intraepidermal nerve fiber density in patients with painful sensory neuropathy. Neurology. Mar 1997; 48(3): 708-11. PMID 9065552 4. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011; 17 Suppl 2: 1-53. PMID 21474420 5. Periquet MI, Novak V, Collins MP, et al. Painful sensory neuropathy: prospective evaluation using skin biopsy. Neurology. Nov 10 1999; 53(8): 1641-7. PMID 10563606 6. Nebuchennykh M, Løseth S, Lindal S, et al. The value of skin biopsy with recording of intraepidermal nerve fiber density and quantitative sensory testing in the assessment of small fiber involvement in patients with different causes of polyneuropathy. J Neurol. Jul 2009; 256(7): 1067-75. PMID 19252773 7. Fabry V, Gerdelat A, Acket B, et al. Which Method for Diagnosing Small Fiber Neuropathy?. Front? 
(2) Devigili G, Tugnoli V, Penza P, et al. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain. Jul 2008; 131(Pt 7): 1912-25. PMID 18524793 9. Walk D, Wendelschafer-Crabb G, Davey C, et al. Concordance between epidermal nerve fiber density and sensory examination in patients with symptoms of idiopathic small fiber neuropathy. J Neurol Sci. Apr 15 2007; 255(1-2): 23-6. PMID 17337273 10. Walk D. Role of skin biopsy in the diagnosis of peripheral neuropathic pain. Curr Pain Headache Rep. Jun 2009; 13(3): 191-6. PMID 19457279 11. Oaklander AL, Herzog ZD, Downs HM, et al. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain. Nov 2013; 154(11): 2310-2316. PMID 23748113 5 12. Boruchow SA, Gibbons CH. Utility of skin biopsy in management of small fiber neuropathy. Muscle Nerve. Dec 2013; 48(6): 877-82. PMID 23553795 13. Hovaguimian A, Gibbons CH. Diagnosis and treatment of pain in small-fiber neuropathy. Curr Pain Headache Rep. Jun 2011; 15(3): 193-200. PMID 21286866 14. Gibbons CH, Illigens BM, Wang N, et al. Quantification of sweat gland innervation: a clinical- pathologic correlation. Neurology. Apr 28 2009; 72(17): 1479-86. PMID 19398703 15. Luo KR, Chao CC, Chen YT, et al. Quantitation of sudomotor innervation in skin biopsies of patients with diabetic neuropathy. J Neuropathol Exp Neurol. Oct 2011; 70(10): 930-8. PMID 21937916 16. Alport AR, Sander HW. Clinical approach to peripheral neuropathy: anatomic localization and diagnostic testing. Continuum (Minneap Minn). Feb 2012; 18(1): 13-38. PMID 22810068 17. Lauria G, Hsieh ST, Johansson O, et al. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. J Peripher Nerv Syst. Jun 2010; 15(2): 79-92. PMID 20626771 18. Blonde L, Umpierrez GE, Reddy SS, et al. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract. Oct 2022; 28(10): 923-1049. PMID 35963508 19. American Academy of Neurology. Evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (guideline detail). 2019; https://www.aan.com/Guidelines/home/GuidelineDetail/316. Accessed November 25, 2024. 20. England JD, Gronseth GS, Franklin G, et al. Evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Muscle Nerve. Jan 2009; 39(1): 106-15. PMID 19086069 21. Centers for Medicare & Medicaid. National Coverage Determination (NCD) for Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (70.2.1). 2002; https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?ncdid=171.. Accessed November 26, 2024.? 

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Medical Policy Nerve Fiber Density Measurement
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 393

BCBSA Reference Number: 2.04.58 (For Plan internal use only) Related Policies
Quantitative Sensory Testing #258

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

Skin biopsy with epidermal nerve fiber density measurement for the diagnosis of small-fiber neuropathy may be considered MEDICALLY NECESSARY when all of the following conditions are met:

  1. Individual presents with symptoms of painful sensory neuropathy; AND
  2. There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); AND
  3. Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation; AND

  4. Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy.

    Skin biopsy with epidermal nerve fiber density measurement is considered INVESTIGATIONAL for all other conditions, including, but not limited to, the monitoring of disease progression or response to treatment.

    Measurement of sweat gland nerve fiber density is INVESTIGATIONAL.

    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.

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Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required. 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.

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.

Description Peripheral Neuropathy Most patients with peripheral neuropathy exhibit evidence of large fiber involvement, characterized by numbness, tingling, loss of deep tendon reflexes, and abnormal electrophysiologic studies. In contrast, damage to small fibers is not detected by routine nerve conduction studies. Patients with small fiber neuropathy, involving myelinated A delta and unmyelinated C fibers, may complain of severe pain and exhibit diminished thermal and pain perception. The pain, which is frequently reported in the feet, is described as burning, prickling, stabbing, jabbing, or tight band-like pressure. If there is involvement of autonomic C fibers, symptoms such as coldness, discoloration, and hyper- or hypohidrosis may be present. Small fiber neuropathy occurs most often in patients with diabetic neuropathy but may also be found in patients with impaired glucose tolerance, severe hypertriglyceridemia, metabolic syndrome, HIV infection, and toxic neuropathy from antiretroviral drugs. For many patients, no specific etiology is identified. Diagnosis Small fiber neuropathy is diagnosed clinically but has traditionally been a diagnosis of exclusion based on clinical findings and the absence of large fiber involvement, as determined by electrophysiologic studies. The disparity between subjective complaints and objective signs increases the difficulty of diagnosis. Also, conditions other than nerve fiber damage, including venous insufficiency, spinal stenosis, myelopathy, and psychosomatic disturbances, may mimic small fiber neuropathy. Skin Biopsy Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve fibers using antibodies to a marker found in peripheral nerves. A specific test to assess intraepidermal nerve fiber (IENF) density and sweat gland nerve fiber density using skin biopsy and immunostaining of the tissue have been developed that allow the identification and counting of intraepidermal and sudomotor nerve fibers. Assessment of nerve fiber density typically involves a 3-mm punch biopsy of skin from the calf (and sometimes foot or thigh). After sectioning by microtome, the tissue is immunostained with anti-protein-gene-product 9.5 antibodies and examined with immunohistochemical or immunofluorescent methods. This technique has improved research and contributed greatly to the understanding of small fiber neuropathy. Skin biopsy with measurement of IENF density has also been investigated as an objective measure for the diagnosis of small fiber neuropathy. Sweat gland nerve fiber density can be assessed from the same tissue prepared for IENF density testing provided that the biopsy sample is of sufficient depth. Tissue samples may also be counterstained to identify the boundaries of the sweat glands better.

3

Treatment There is no curative treatment for small fiber peripheral neuropathy. Medications may be provided for pain management, and for some etiologies, treatment of the underlying condition (eg, glucose control, intravenous immunoglobulin, or plasma exchange) may be given to reduce the progression of the disease and its symptoms.

Summary Skin biopsy is used to assess the density of epidermal (intraepidermal) and sweat gland (sudomotor) nerve fibers using antibodies to a marker found in peripheral nerves. This procedure is proposed as an objective measure of small fiber neuropathy by identifying a reduction in the density of nerve fibers. Summary of Evidence For individuals with suspected idiopathic small fiber neuropathy who receive intraepidermal nerve fiber (IENF) density measurement, the evidence includes reports assessing whether IENF density measurement is technically reliable, clinically valid, and clinically useful. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. Techniques to measure IENF density have led to an improved understanding of the relation between the loss of small nerve fibers and symptoms of peripheral neuropathy. The literature has also indicated that low IENF density may provide supportive evidence of a lesion in the peripheral somatosensory system. For example, there is a significant decrease in average IENF density in patients diagnosed with small fiber neuropathy compared with controls, and an IENF density of 4 to 8 per mm in the calf is near the fifth percentile of normal values, suggesting an increased probability of small fiber neuropathy below these cutoffs. For individuals who have symptoms suggestive of neuropathy but no evidence of large nerve neuropathy and no disease associated with neuropathy (eg, diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy), establishing a cause for the symptoms is problematic. Thus, IENF density measurement may help to diagnose idiopathic small fiber neuropathy in those who have no evidence of large fiber neuropathy and no known cause of neuropathy. The evidence is sufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have an established diagnosis of small fiber neuropathy who receive repeated IENF density measurement, the evidence is limited. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. A number of trials are ongoing or have recently been completed; they assess the efficacy of activity and medications on small fiber neuropathy. If successful, there might be a role for repeated IENF density measurements to result in a change in management (eg, changing dose or class of medication). However, current treatments for small fiber neuropathy only palliate symptoms and do not modify the underlying changes in nerve fiber density in patients with symptomatic neuropathy. There is no evidence that monitoring the progression of neuropathy has clinical utility. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have suspected small fiber neuropathy who receive sweat gland nerve fiber density measurement, the evidence includes comparisons with control values. Relevant outcomes are test accuracy, change in disease status, symptoms, and quality of life. Measurement of sweat gland nerve fiber density may lead to an improved understanding of the relation between the loss of sudomotor nerve fibers and symptoms of peripheral neuropathy. However, no studies were identified that evaluated the diagnostic accuracy of sweat gland nerve fiber density measurement. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 2/2025 Annual policy review. References updated. Policy statements unchanged. 1/2024 Annual policy review. References updated. Policy statements unchanged.

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2/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 1/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2017 Annual policy review. New investigational indications described. Title changed. Effective 5/1/2017. 12/2014 Annual policy review. New references added. 1/2014 Annual policy review. New references added. 11/1/12 New policy describing ongoing coverage and non-coverage. 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. England JD, Gronseth GS, Franklin G, et al. Practice Parameter: evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Report of the American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, and American Academy of Physical Medicine and Rehabilitation. Neurology. Jan 13 2009; 72(2): 177-84. PMID 19056667
  2. McArthur JC, Stocks EA, Hauer P, et al. Epidermal nerve fiber density: normative reference range and diagnostic efficiency. Arch Neurol. Dec 1998; 55(12): 1513-20. PMID 9865794
  3. Holland NR, Stocks A, Hauer P, et al. Intraepidermal nerve fiber density in patients with painful sensory neuropathy. Neurology. Mar 1997; 48(3): 708-11. PMID 9065552
  4. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011; 17 Suppl 2: 1-53. PMID 21474420
  5. Periquet MI, Novak V, Collins MP, et al. Painful sensory neuropathy: prospective evaluation using skin biopsy. Neurology. Nov 10 1999; 53(8): 1641-7. PMID 10563606
  6. Nebuchennykh M, Løseth S, Lindal S, et al. The value of skin biopsy with recording of intraepidermal nerve fiber density and quantitative sensory testing in the assessment of small fiber involvement in patients with different causes of polyneuropathy. J Neurol. Jul 2009; 256(7): 1067-75. PMID 19252773
  7. Fabry V, Gerdelat A, Acket B, et al. Which Method for Diagnosing Small Fiber Neuropathy?. Front Neurol. 2020; 11: 342. PMID 32431663
  8. Devigili G, Tugnoli V, Penza P, et al. The diagnostic criteria for small fibre neuropathy: from symptoms to neuropathology. Brain. Jul 2008; 131(Pt 7): 1912-25. PMID 18524793
  9. Walk D, Wendelschafer-Crabb G, Davey C, et al. Concordance between epidermal nerve fiber density and sensory examination in patients with symptoms of idiopathic small fiber neuropathy. J Neurol Sci. Apr 15 2007; 255(1-2): 23-6. PMID 17337273
  10. Walk D. Role of skin biopsy in the diagnosis of peripheral neuropathic pain. Curr Pain Headache Rep. Jun 2009; 13(3): 191-6. PMID 19457279
  11. Oaklander AL, Herzog ZD, Downs HM, et al. Objective evidence that small-fiber polyneuropathy underlies some illnesses currently labeled as fibromyalgia. Pain. Nov 2013; 154(11): 2310-2316. PMID 23748113

5

  1. Boruchow SA, Gibbons CH. Utility of skin biopsy in management of small fiber neuropathy. Muscle Nerve. Dec 2013; 48(6): 877-82. PMID 23553795
  2. Hovaguimian A, Gibbons CH. Diagnosis and treatment of pain in small-fiber neuropathy. Curr Pain Headache Rep. Jun 2011; 15(3): 193-200. PMID 21286866
  3. Gibbons CH, Illigens BM, Wang N, et al. Quantification of sweat gland innervation: a clinical- pathologic correlation. Neurology. Apr 28 2009; 72(17): 1479-86. PMID 19398703
  4. Luo KR, Chao CC, Chen YT, et al. Quantitation of sudomotor innervation in skin biopsies of patients with diabetic neuropathy. J Neuropathol Exp Neurol. Oct 2011; 70(10): 930-8. PMID 21937916
  5. Alport AR, Sander HW. Clinical approach to peripheral neuropathy: anatomic localization and diagnostic testing. Continuum (Minneap Minn). Feb 2012; 18(1): 13-38. PMID 22810068
  6. Lauria G, Hsieh ST, Johansson O, et al. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. J Peripher Nerv Syst. Jun 2010; 15(2): 79-92. PMID 20626771
  7. Blonde L, Umpierrez GE, Reddy SS, et al. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract. Oct 2022; 28(10): 923-1049. PMID 35963508
  8. American Academy of Neurology. Evaluation of distal symmetric polyneuropathy: role of autonomic testing, nerve biopsy, and skin biopsy (guideline detail). 2019; https://www.aan.com/Guidelines/home/GuidelineDetail/316. Accessed November 25, 2024.
  9. England JD, Gronseth GS, Franklin G, et al. Evaluation of distal symmetric polyneuropathy: the role of autonomic testing, nerve biopsy, and skin biopsy (an evidence-based review). Muscle Nerve. Jan 2009; 39(1): 106-15. PMID 19086069
  10. Centers for Medicare & Medicaid. National Coverage Determination (NCD) for Services Provided for the Diagnosis and Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (aka Diabetic Peripheral Neuropathy) (70.2.1). 2002; https://www.cms.gov/medicare-coverage- database/details/ncd-details.aspx?ncdid=171.. Accessed November 26, 2024.
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