BlueCross BlueShield of Tennessee Medical Policy Manual

Surface Electromyography (sEMG)

DESCRIPTION

Surface electromyography (sEMG) is a non-invasive procedure involving the detection, recording and interpretation of the electric activity of groups of muscles at rest (i.e., static) and during activity (i.e., dynamic). The procedure is performed using a single or an array of electrodes placed on the skin surface over the muscles to be tested. Recording can also be made using a hand-held device, which is applied to the skin surface at different sites. Electrical activity is assessed by computer analysis of the frequency spectrum, amplitude, or root mean square of the electrical action potential. Surface electromyography is occasionally used as an aid to diagnose neuromuscular disorders, determine the need for surgery in individuals with low back pain, and assist in evaluating the prognosis of disorders involving muscle lesions. The technology has also been utilized to monitor the effects of rehabilitation programs and evaluate muscular function in occupational and sports programs.

Needle electromyography is an invasive procedure that records the electrical activity of individual muscles and is considered a more reliable technology.

Paraspinal sEMG, also referred to as paraspinal EMG scanning, has been explored 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 ROM, or postural disorders. The technique is performed using electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises.

Note: This policy only applies to the application of surface electromyography to the skin and does not apply to electromyography studies of the anal or urethral sphincter or needle EMG.

POLICY

See also:

IMPORTANT REMINDERS

ADDITIONAL INFORMATION 

There are no data on the impact of SEMG on patient management or health outcomes. The evidence is insufficient to determine the effects of the technology on health outcomes.

SOURCES

American Pain Society (APS). (2009). Clinical guideline for the evaluation and management of low back pain. Retrieved October 3, 2017 from http://americanpainsociety.org/uploads/education/guidelines/evaluation-management-lowback-pain.pdf.

Bandpei, M., Rahmani, N., Majdoleslam, B., Abdollahi, I., Ali, S., and Ahmad, A. (2014) Reliability of surface electromyography in the assessment of paraspinal muscle fatigue: an updated systemic review. Journal of Manipulative and Physiological Therapeutics, 37 (7), 511-521. (Level 2 evidence)

BlueCross BlueShield Association. Medical Policy Reference Manual. (6:2017). Paraspinal surface electromyography to evaluate and monitor back pain (2.01.35). Retrieved October 3, 2017 from BlueWeb. (22 articles and/or guidelines reviewed)

Cahaba Government Benefit Administrators, LLC. (2017, February). LCD for Medicine: Physical Therapy - Outpatient (L34310) Retrieved October 3, 2017 from  https://www.cms.gov.

Ciesielska, J., Lisinski, P., Bandosz, A., Huber, J., Kulczk, A., & Lipiec, J. (2015). Hip strategy alterations in patients with history of low disc herniation and non-specific low back pain measured by surface electromyography and balance platform. Acta of Bioengineering and Biomechanics, 17 (3), 103-108. Abstract retrieved January 13, 2016 from PubMed database.

Kinsella, R., & Pizzari, T. (2017). Electromyographic activity of the shoulder muscles during rehabilitation exercises in subjects with and without subacromial pain syndrome: a systematic review. Shoulder Elbow, 9 (2), 112-126. Abstract retrieved October 3, 2017 from PubMed database.

Maranesi, E., Fioretti, S., Ghetti, G., Rabini, R., Burattini, L., Mercante, O., et al. (2015). The surface electromyographic evaluation of the Functional Reach in elderly subjects. Journal of Electromyography and Kinesiology. Epub ahead of print. Abstract retrieved January 13, 2016 from PubMed database.

Subbu, R., Weiler, R., & Whyte, G. (2015). The practical use of surface electromyography during running: does the evidence support the hype? A narrative review. BMJ Open Sport & Exercise Medicine, doi:10.1136/b,kse,=2015-000026. (Level 2 evidence)

U. S. Food and Drug Administration. (2004, January). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K031995. Retrieved September 28, 2009 from http://www.accessdata.fda.gov. 

U. S. Food and Drug Administration. (2007, August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K063447. Retrieved November 3, 2016 from: http://www.accessdata.fda.gov.

ORIGINAL EFFECTIVE DATE:  4/1981

MOST RECENT REVIEW DATE:  10/26/2017

ID_BT

Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.

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