Humana Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Form

Description

Nerve Conduction Testing Nerve conduction testing, also known as nerve conduction studies (NCS) and nerve conduction velocity (NCV) testing, measures the speed of conduction of impulses through a nerve. These measured impulses are generated by placing a stimulating electrode on the skin over the nerve. Recording electrodes are placed at various distances from the stimulating electrode. The distance between electrodes and the time it takes for electrical impulses to travel between electrodes are used to determine the speed of the nerve signals.

There are two parts to NCS: testing motor nerves and testing sensory nerves.

Motor NCS

Motor NCS are performed by stimulating two different points along a nerve and the impulse is measured by an electrode that is placed over the muscle being stimulated by that nerve. This measure is called the latency and is measured in milliseconds. The size of the response is called the amplitude and is measured in millivolts.

Sensory NCS

Sensory NCS are measured with a single stimulating electrode and a single recording electrode. This test is calculated based upon the latency and the distance between the stimulating and recording electrode.

Additional Types of NCS

• F-wave study includes an electrical stimulation that is applied to the skin surface proximal to the distal portion of a nerve so that the impulse travels both toward the muscle fiber and back to the motor neurons of the spinal cord.
• H-reflex study uses stimulation of a nerve and records the reflexive electrical discharge from a muscle in the limb. It also measures the conduction between the limb and spinal cord. The impulses going toward the spinal cord are known as afferent impulses and those moving away from the spinal cord are efferent impulses.

NCS are most often done in conjunction with an electromyography (EMG) (needle EMG). An EMG is a test which measures muscle response to nerve stimulation. An instrument converts the electrical activity associated with functioning skeletal muscle into a visual record or into sound. This allows the electrical activity of the underlying muscle in response to electrical or nerve stimulation to be measured. A needle EMG refers to the recording and study of electrical activity of muscles using needle electrodes inserted into specific muscles. Needle EMG evaluation, in combination with nerve conduction studies, is the preferred diagnostic tool for evaluating muscular dysfunction.

Neuromuscular junction testing measures the one directional chemical or neurotransmitter communication between the peripheral nerve and muscle. The neuromuscular junction structure consists of presynaptic endplate region on the nerve at the neuromuscular junction.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Neuromuscular Junction Disorder Tests

muscle fiber. Repetitive nerve stimulation (RNS) and at times, single fiber electromyography (SFEMG) are key tests in confirmation of a neuromuscular junction disorder.

Automated Handheld Devices for Nerve Conduction Testing

Automated handheld devices, also known as point of care devices, perform limited nerve conduction tests and do not supplement, replace or duplicate traditional nerve conduction tests. Examples of these devices include, but may not be limited to, the ADVANCE NCS system, Brevio NCS, NC-Stat DPNCheck system and the NC–Stat system. (Refer to Coverage Limitations section)

Blink Reflexes

Blink reflexes, also known as corneal reflexes, evaluate the trigeminal (cranial nerve 5) and the facial nerve (cranial nerve 7) and their connections in the brainstem. The blink reflex has two components, an early R1 and late R2 response measuring side to side differences. Abnormal blink reflexes may be found in demyelinating polyneuropathies such as Guillain-Barre.

Somatosensory Evoked Potentials

Somatosensory evoked potentials (SSEP or SEP) are responses (electrical signals) produced by the central nervous system as a result of a stimulus. SSEP, also known as cerebral sensory evoked potentials, are noninvasive studies performed by repetitive, submaximal electrical stimulation of a sensory or mixed sensorimotor peripheral nerve. The averaged response times are recorded from electrodes that are placed over the proximal portion of the nerve that is stimulated in addition to the plexus, spine and scalp. This testing is most useful in assessing the spinal nerve roots, spinal cord or brainstem for evidence of delayed nerve conduction. SSEP may also be used during surgery for certain indications. For information regarding intraoperative indications for SSEP, please refer to the Intraoperative Neurological Monitoring Medical Coverage Policy.

Visual Evoked Potentials

Visual evoked potentials (VEP), also known as visual evoked responses (VER), measure and record the function of the optic nerve or central nervous system to identify interruptions in transmission along the optic nerve pathway. During testing, electrodes are placed on the scalp to record the electric signals as the individual looks at a computer screen watching a checkerboard pattern flash for several minutes. For information regarding intraoperative VEP, please refer to the Intraoperative Neurological Monitoring Medical Coverage Policy.

Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0337-023 Page: 4 of 23
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Macro Electromyography

Macro electromyography is a technique to measure the entire motor unit (anterior horn cell, its axon, the neuromuscular junctions and the muscle fibers innervated by the motor neuron) using a concentric or single fiber electrode. (Refer to Coverage Limitations section)

Surface Electromyography

Surface electromyography (SEMG), also known as surface scanning EMG, is a technique to measure muscle activity noninvasively using surface electrodes and conduction gel placed on the skin overlying the muscle.

There are a number of variations of SEMG. Paraspinal EMG (also referred to as paraspinal SEMG), has been investigated as a diagnostic test to evaluate the paraspinal muscles in an individual with back pain. Spinoscopy, another purported diagnostic test, combines the use of SEMG and video recording in an integrated computer system.

Spine Matrix Scans

Spine matrix scans (also known as lumbar matrix scans) are theorized to collect thousands of bioelectrical signals from the back and reconstruct them into easily interpreted images. Another test that incorporates SEMG as a component in the evaluation of chronic pain is the Neurophysiologic Pain Profile (NPP). (Refer to Coverage Limitations section)

Neuromuscular Ultrasound

Neuromuscular ultrasound is a diagnostic technique that uses high frequency sound waves that form two dimensional (2D) images to exam muscles and nerves. (Refer to Coverage Limitations section)

Coverage Determination | Nerve Conduction Testing

Humana members may be eligible under the Plan for nerve conduction testing when performed in conjunction with a needle EMG for the following indications:

1. Carpal tunnel syndrome (CTS) with failure of 4 weeks of conservative treatment under the direction of a healthcare professional, which includes:
   • Wrist splint; AND

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   Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

   EITHER or BOTH of the following:

   • Steroid (methylprednisolone) injections if medically appropriate and not contraindicated; AND/OR
   • Medications (eg, NSAIDs, oral steroids) if medically appropriate and not contraindicated.

   For information regarding coverage determination of CTS NCS testing (without a needle EMG)

   For information regarding coverage Carpal Tunnel Syndrome Surgical Treatments, please refer to Carpal Tunnel Syndrome Surgical Treatments Medical Coverage Policy.

2. Cervical radiculopathy with the following:

• Failure of 4 weeks of conservative treatment under the direction of a healthcare professional, which includes:
  • Activity/lifestyle modification; AND
  • Medications, injectable or oral (eg, NSAIDs, non-narcotic analgesics, steroids) if medically appropriate and not contraindicated; AND
  • Physical therapy (PT) including home exercise program (HEP) (for information regarding coverage determination/limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
• Persistent or progressive radicular symptoms (eg, pain radiating down one or both arms); AND
• Unexplained by imaging studies (eg, magnetic resonance imaging [MRI], myelogram); OR

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• Lumbar radiculopathy with the following:
  1. Failure of 4 weeks of conservative treatment under the direction of a healthcare professional, which includes:
     • Activity/lifestyle modification; AND
     • Medications, injectable or oral (eg, NSAIDs, non-narcotic analgesics, steroids) if medically appropriate and not contraindicated; AND
     • PT including HEP (for information regarding coverage determination /limitations, please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy); AND
  2. Persistent or progressive radicular symptoms (eg, leg pain radiating to the level of the knee or more distally); AND
  3. Unexplained by imaging studies (eg, MRI, myelogram); OR
• Diagnostic aid for generalized neuropathies with any of the following:
  1. Differential diagnosis of symptom based complaints (eg, cramp, fatigue, numbness, pain, tingling, twitching [fasciculation] and weakness) provided the clinical assessment was inconclusive; OR
  2. Individual with diabetes having persistent or progressive symptoms of neuropathy despite conservative treatments (eg, medications, well fitted shoes) when clinical features are atypical or the diagnosis is unclear; OR
  3. Physical examination findings of muscle atrophy with no known etiology (eg, diabetes, hypothyroidism, lupus, rheumatoid arthritis, sensory loss or weakness); OR
  4. Ulnar neuropathy at the elbow or wrist with failure of 4 weeks of conservative treatment under the direction of a healthcare professional, which includes:
     • Activity/lifestyle modification; AND
     • Soft foam elbow pad use; OR
  5. Guillain-Barre syndrome; OR
  6. Identifiable compressive lesion (eg, cysts tumors); OR
  7. Mononeuropathy (eg, Bell’s palsy of the facial nerve); OR
  8. Motor neuropathy (eg, amyotrophic lateral sclerosis [ALS]); OR
  9. Muscular dystrophy; OR
  10. Myasthenia gravis; OR
  11. Myopathy (eg, dermatomyositis, polymyositis, congenital myopathies); OR
  12. Peroneal palsy with foot drop; OR
  13. Plexopathy; OR
  14. Polyneuropathy (eg, distal symmetric, hereditary [Charcot-Marie Tooth disease]); OR
  15. Post-polio syndrome; OR
  16. Tarsal tunnel syndrome when clinical documentation demonstrates numbness and pain isolated to the foot; OR
  17. Traumatic nerve lesions, for diagnosis and prognosis (eg, spinal cord injury, trauma to nerves); OR
  18. Unexplained peripheral neuropathy with pain of a neuropathic pattern, and with demonstrated motor loss or sensory loss; all of unknown etiology

Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0337-023 Page: 7 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may be eligible under the Plan for nerve conduction testing without a needle EMG, if the above criteria are met AND for the following indications:

• Individual on current anticoagulant therapy (eg, Coumadin, direct thrombin inhibitors [eg, Pradaxa]); OR
• Individual being evaluated for carpal tunnel syndrome; OR
• Individual with the presence of lymphedema

Blink Reflexes

Humana members may be eligible under the Plan for blink reflex testing (95933) to evaluate diseases involving cranial nerve five (trigeminal) and cranial nerve seven (facial) (eg, demyelinating conditions such as Guillain-Barre or chronic inflammatory demyelinating polyneuropathy [CIDP], facial pain).

Neuromuscular Junction Testing

Humana members may be eligible under the Plan for neuromuscular junction testing (95937) when documented signs and symptoms are suspected to be caused by a neuromuscular junction disorder (eg, botulinum toxicity, Lambert-Eaton myasthenic syndrome, myasthenia gravis).

Somatosensory Evoked Potentials

Humana members may be eligible under the Plan for nonoperative somatosensory evoked potentials for the following indications:

• Coma; OR
• Multiple sclerosis (diagnosis not confirmed by MRI or CT); OR
• Myoclonus; OR
• Nontraumatic spinal cord lesions (eg, cervical spondylosis); OR
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• Spinal cord trauma; OR
• Spinocerebellar degeneration; OR
• Subacute combined degeneration of the spinal cord (eg, Lichtheim disease); OR
• Suspicion of progressive polyneuropathy of diabetes only where standard nerve conduction studies are inconclusive

Note: The criteria for nerve conduction testing, somatosensory and visual evoked potentials are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Testing Frequency/Number of Studies

Humana members may be eligible under the Plan for nerve conduction testing, neuromuscular junction testing OR SSEP testing when the above criteria are met for no more than two testing sessions per benefit plan year.

Commercial Plan members: requests for testing beyond two testing sessions per benefit plan year require review by a medical director.

The following table provides a reasonable maximum number of studies performed per indication necessary for a physician to arrive at a diagnosis in 90% of individuals with that final diagnosis. The number in each column represents the number of studies recommended.

2022 Current Procedural Terminology (CPT)

Type of Study/Maximum Number of Studies

Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0337-023 Page: 10 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Data is from 2022 CPT Manual Appendix L- Listing of Sensory, Motor and Mixed Nerves. American Medical Association.

Nerve Conduction Testing, Somatosensory and Visual Evoked Potentials, Surface Electromyography Effective Date: 03/23/2023 Revision Date: 03/23/2023 Review Date: 03/23/2023 Policy Number: HUM-0337-023 Page: 11 of 23

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Visual Evoked Potentials

Humana members may be eligible under the Plan for VEP for the following indications:

• Diagnosis and monitoring of multiple sclerosis; OR
• Diagnosis of neuromyelitis optica; OR
• Suspected disorders of the optic nerve or optic chiasm not explained by the following:
  • Computed tomography (CT); OR
  • Infectious diseases (eg, Lyme disease); OR
  • MRI; OR
  • Metabolic diseases (eg, vitamin B12 deficiency)

Coverage Nerve Conduction Testing

Coverage Limitations

Nerve Conduction Testing Humana members may NOT be eligible under the Plan for nerve conduction testing, neuromuscular junction testing OR SSEP for any indications other than those listed above OR for the following indications:

• Monitoring disease intensity or treatment efficacy in end-stage renal disease (ESRD) or polyneuropathy of diabetes; OR
• NCS performed without a needle* EMG except when above criteria are met; OR
• Neuromuscular junction testing or SSEP for temporomandibular joint disorders; OR
• Screening for general population in absence of symptoms; OR
• Screening for polyneuropathy of diabetes or ESRD; OR
• SSEP for acute radiculopathies; OR
• SSEP for peripheral nerve lesions; OR
• SSEP for the diagnosis of a focal neuropathy such as carpal tunnel syndrome or ulnar nerve entrapment; OR
• Testing performed without direct supervision of trained electrodiagnostic physician

These are considered not medically necessary as defined in the member’s individual certificate.

Please refer to the member’s individual certificate for the specific definition.

Automated Handheld Devices

Humana members may NOT be eligible under the Plan for nerve conduction testing by the following methods:

• NCS performed utilizing a preconfigured electrode array or a portable or handheld device (eg, ADVANCE NCS system, Brevio NCS, NC-Stat DPNCheck and NC-Stat system)

This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Blink Reflexes

Humana members may NOT be eligible under the Plan for blink reflex testing for any indications other than those listed above. This is considered experimental/ investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Macro and Surface EMG

Humana members may NOT be eligible under the Plan for noninvasive electromyography, for any indication, or by any technique including, but may not be limited to:

• Macro EMG; OR
• Surface EMG, including any of the following:
  • Neurophysiologic Pain Profile (NPP); OR
  • Paraspinal EMG; OR
  • Spine matrix scan (lumbar matrix scan); OR
  • Spinoscopy

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Neuromuscular Ultrasound

Humana members may NOT be eligible under the Plan for neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

VEP

Humana members may NOT be eligible under the Plan for VEP for any indications other than those listed above, including the diagnosis and monitoring of glaucoma. This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) states: Nerve conduction studies performed independent of needle EMG may only provide a portion of the information needed to diagnose muscle, nerve root and most nerve disorders.⁷ When NCS is used on its own, without integrating needle EMG findings or when an individual relies solely on a review of NCS data, the results can be misleading and important diagnoses may be missed. An Individuals may thus be subjected to incorrect, unnecessary, and potentially harmful treatment interventions.⁷

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Additional information about chronic pain, electrodiagnostic testing, low back pain, nerve conditions or neuromuscular disorders may be found from the following websites:

Background

• American Academy of Orthopaedic Surgeons
• National Institute of Neurological Disorders and Stroke
• National Library of Medicine

Medical Alternatives

Alternatives to nerve conduction testing or somatosensory evoked potentials include, but may not be limited to:

• Imaging studies

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.