Somatosensory Evoked Potentials (Non-intraoperative)
DESCRIPTION
Somatosensory evoked potentials (SEPs) are one type of evoked potential (EP) which are generated by stimulation of afferent peripheral nerve fibers elicited by electrical, tactile, or other stimuli. By following mixed nerve or sensory nerve stimulation, SEPs can be recorded over more proximal portions of the peripheral and central nervous system including peripheral nerves, spinal cord, and/or brain. By stimulating the skin in various dermatomal areas, an SEP may also be recorded (dermatomal somatosensory evoked potential or DSEP).
SEPs may be used to assess the functional integrity of the central and peripheral sensory pathways. These are noninvasive studies performed by repetitive submaximal stimulation of a sensory or mixed sensorimotor peripheral nerve and recording averaged responses from electrodes placed over proximal portions of the nerve stimulated, plexus, spine, and scalp. Amplitude, peak, and interpeak latency measurements with side-to-side comparisons are used to assess abnormalities
POLICY
Somatosensory evoked potentials (non-intraoperative) in the diagnosis of the following diseases/conditions are considered medically necessary:
Diseases/conditions of the brain and brainstem (e.g., multiple sclerosis, diseases of myelin [e.g., adrenoleukodystrophy, adrenomyeloneuropathy], hereditary system degenerations [e.g., Friedreich's ataxia], myoclonus, coma)
Diseases/conditions of the spinal cord (e.g., spinal cord trauma, vitamin B12 deficiency, cervical spondylosis and myelopathy, syringomyelia, hereditary spastic paraplegia, metabolic disorders [chronic renal failure and juvenile diabetes], transverse myelitis and multiple sclerosis, vascular lesions, spinal cord tumors, myelomeningocele, tethered cord syndrome)
Lumbosacral spinal stenosis resulting in chronic compression, a disease/condition of the ventral rootlets and roots, as evidenced by CT, MRI or myelogram
Hereditary neuropathies, diabetic neuropathy, inflammatory polyradiculoneuropathies, infectious disorders and toxic neuropathies. These are diseases/conditions of the peripheral nervous system.
Somatosensory evoked potentials (non-intraoperative) in the diagnosis of other diseases/conditions, including, but not limited to, the following are considered investigational:
Acute radiculopathies (e.g., acute lumbosacral radiculopathy), thoracic root disorders and cervical root diseases. These are diseases/conditions of the ventral rootlets and roots; and
Acute inflammatory demyelinating polyradiculoneuropathy (AIDP), focal neuropathy (including entrapment neuropathies, carpal tunnel syndrome, lateral femoral cutaneous neuropathy, medial and lateral plantar neuropathy, saphenous neuropathy, intercostal neuropathy, trigeminal neuropathy and plexopathy). These are diseases/conditions of the peripheral nervous system.
See also:
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
BlueCross BlueShield of Tennessee has adopted the position of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) in regard to the investigational uses of sensory evoked potentials (SEPs).
Well-designed studies in peer-reviewed journals, which evaluate the clinical importance of somatosensory evoked potentials for conditions listed above as investigational, are lacking.
The decision to perform an SEP must be based upon a history and physical examination findings obtained prior to the performance of the procedure and evident in the individual's record.
As specified by the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), evoked potential (EP) records should contain the following information:
The individual's name, identifying number (if applicable), age, and gender.
The date of examination.
The technologist's name or initials, as well as the name of the physician who interpreted the studies.
The derivation recorded in each channel in the form of abbreviated accepted designations of the electrode locations connected to the input terminals 1 and 2 of the amplifier, in that order.
The type, intensity, and rate of presentation of the stimuli, and the side and site of stimulation.
Other information relative to test results, including the nerve stimulated and the side.
The number of individual trials averaged.
The time calibration, corresponding to the epoch averaged, with subdivisions appropriate to the temporal dimensions of the EP recorded. Whenever a pre-stimulus baseline or post-stimulus delay is used, it should be clearly displayed.
The voltage calibration indicating the amplitude of deflection produced in terms of sensitivity (voltage/linear distance).
Modern EP equipment will leave marks indicating the points at which "measurements" were taken. If such features are not available, the technologist or physician must mark by hand the peaks recognized and the sites at which they were measured.
The physician performing SEPs must be trained or certified in the application, performance and interpretation of electrodiagnostic testing and licensed by the state in which the studies are performed. The technician delegated to perform SEPs must be trained in electrodiagnostic testing and licensed or certified by the state (or by one of the state's health related boards if licensure or certification as a technician does not exist in a given state) in which the studies are performed. See also: Staff Supervision Requirements for Delegated Services.
According to the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), becoming credentialed by a national examining organization that assesses accuracy of knowledge of EPs is the only objective method of demonstrating competency in the interpretation of EP studies. Eligibility requirements for the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) examination include completion of an accredited residency in neurology or physical medicine and rehabilitation with a minimum of six months of full-time equivalent formal clinical neurophysiology training. Another requirement is Board certification by the American Board of Psychiatry and Neurology (neurology or psychiatry) or the American Board of Physical Medicine and Rehabilitation (physiatry). One year of additional post-residency experience is also required. Current interpretation of the Committee on Electrodiagnosis of the American Chiropractic Association Council on Neurology is that electrodiagnostic evaluation/interpretation in the assessment of neurological disorders should be performed by a board eligible or board certified Chiropractic Neurologist.
According to the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), a written and signed interpretation must be provided for each clinical EP study. The interpretation should begin with the object of the examination and a concise summary of the clinical history available at the time of recording. The type of EP recorded should be briefly outlined and information provided on any relevant medications received by the patient either as a treatment or in preparation for the test. The results of relevant ancillary tests should also be presented. Copies of the waveforms recorded should be included or made available upon request.
SOURCES
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). (Endorsed by the American Academy of Neurology, the American Academy of Physical Medicine and Rehabilitation and the American Association of Neuromuscular & Electrodiagnostic Medicine). Recommended policy for electrodiagnostic medicine. Retrieved October 2, 2006 from http://www.aanem.org/documents/recpolicy.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Guidelines in Electrodiagnostic Medicine. (1999). Chapter 5: Somatosensory Evoked Potentials: Clinical Uses. Muscle Nerve, 22 (Supplement 8), S111-S118.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Guidelines in Electrodiagnostic Medicine. (1999). Chapter 6: Guidelines in somatosensory evoked potentials. Muscle Nerve, 22 (Supplement 8), S123-S138.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). (1999). Position Statement. Who is qualified to practice electrodiagnostic medicine? Retrieved October 2, 2006 from http://www.aanem.org/documents/who_is_qualified.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). (1999). Position Statement. Responsibilities of an electrodiagnostic technologist. Retrieved October 2, 2006 http://www.aanem.org/practiceissues/positionstatements/responsibilities_of_an_EDXTech.cfm.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Position Statement. (2000). Job description for electrodiagnostic technologists. Retrieved October 2, 2006 from http://www.aanem.org/practiceissues/positionstatements/job_descriptions_for_edxtech.cfm.
American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). (2009). Position Statement. Technologists conducting nerve conduction studies and somatosensory evoked potential studies independently to be reviewed by a physician at a later time. Retrieved September 2, 2009 from http://www.aanem.org/practiceissues/positionstatements/TechsNCSSEP.cfm.
ORIGINAL EFFECTIVE DATE: 7/1982
MOST RECENT REVIEW DATE: 10/8/2009
ID_BT
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