Summary Of Evidence

N/A

Analysis of Evidence

N/A

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Neuromuscular junction testing involves the stimulation of an individual motor nerve by means of repetitive electrical impulses with measurement of the resulting electrical activity of a muscle supplied by that nerve. Supramaximal electrical stimuli are delivered to the nerve. A surface electrode over, or a percutaneous electrode placed in a corresponding muscle, records the evoked muscle action potentials using standard nerve conduction study techniques. The nerve is then stimulated electrically in a repetitive train at 2-3 Hertz (Hz), or in special circumstances at higher rates up to 50 Hz. In diseases of the neuromuscular junction, characteristic changes of a progressive decrease (decrement) in the compound action potential amplitude may be seen during the repetitive stimulation.

Covered Indications

Neuromuscular junction testing by repetitive stimulation may be reasonable and necessary to diagnose patients with fatigable weakness who are being evaluated for possible disease of the neuromuscular junction. These diseases may include myasthenia gravis or Lambert Eaton myasthenic syndrome (LEMS), as well as botulinum toxicity. Rarely, exposure to certain drugs such as aminoglycoside antibiotics or D-Penicillamine can potentiate myasthenic symptoms. Patients in intensive care unit (ICU) settings who experience continued weakness after a critical illness which has required paralyzation for mechanical ventilation may also be candidates for this type of testing.

Limitations

Neuromuscular junction testing by repetitive motor nerve stimulation is not considered reasonable or necessary for indications other than those listed above.

Examples of tests or procedures not covered under repetitive nerve stimulation services include quantitative sensory testing by any means and sensory nerve conduction threshold testing. Tests depending on the patient’s subjective response to single or repetitive stimulation (electrical, vibratory, thermal or tactile), regardless of whether or not these data are analyzed and presented through electronic or computerized systems, also fail to satisfy the definition of neuromuscular junction testing (repetitive stimulation, paired stimuli) each nerve, any one method. 

NOTE: Quantitative sensory testing (QST) uses electrical or mechanical stimuli at varying amplitudes to evoke patients’ subjective responses. Such tests are designed to be helpful in characterizing various types and degrees of neural damage or impairment. However, the clinical usefulness of such tests remains unclear. One such device is the Current Perception Threshold/Sensory Nerve Conduction Threshold test (CPT/sNCT). CMS has determined that this test is not covered since there is insufficient scientific or clinical evidence to consider this device as reasonable and necessary within the meaning of 1862(a)(1)(A) of the Social Security Act. (See also CMS Publication 100-03, Medicare National Coverage Determinations [NCD] Manual, Chapter 1, Part 2, Section 160.23).  Another such device is the pressure-specified sensory device (PSSD), which relies on a pressure stimulus to determine a sensory threshold. 

Neuromuscular junction testing by repetitive stimulation is considered not reasonable and necessary for the diagnosis or treatment of diabetic neuropathy.

Neuromuscular junction testing by repetitive stimulation is considered not reasonable and necessary for the diagnosis or treatment of carpal or tarsal tunnel syndrome.

Neuromuscular junction testing by repetitive stimulation may be reasonable and necessary for certain physical signs and symptoms (e.g., diplopia, dysphagia, weakness, fatigue) only when the medical record indicates that such signs and symptoms are suspected to be caused by a neuromuscular junction disorder.

This LCD imposes frequency limitations. For frequency limitations please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules. Refer to Billing and Coding: Neuromuscular Junction Testing, A56785, for applicable CPT/HCPCS codes and diagnosis codes.

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this LCD.