Electromyography and Nerve Conduction Studies (Electrodiagnostic Assessment)
Electromyography (EMG) and nerve conduction studies (NCS), collectively known as electrodiagnostic (EDX) assessment, are intended to evaluate the electrical functioning of muscles and peripheral nerves. These tests are used as diagnostic aids for the evaluation of myopathy and peripheral neuropathy by identifying, localizing and characterizing electrical abnormalities in the skeletal muscles and peripheral nerves. These tests are performed when there is a clinical suspicion for a myopathic or neuropathic process and when clinical examination and standard laboratory testing are unable to make a definitive diagnosis. The results of these tests do not generally provide a specific diagnosis; however, they provide additional information that assists the physician in characterizing a clinical syndrome.
Nerve conduction studies performed without needle EMG may be missing valuable data that could be essential to determine an accurate diagnosis. Dissociation of Nerve Conduction Studies (NCS) and the EMG into separate reports is generally inappropriate.
Electromyography (EMG) and nerve conduction studies (NCS) are considered medically necessary for the following indications:
Focal neuropathies, entrapment neuropathies, compressive lesions/syndromes such as carpal tunnel syndrome, ulnar neuropathies or root lesions, for localization
Traumatic nerve lesions, for diagnosis and prognosis
Generalized neuropathies, such as diabetic, uremic, metabolic, toxic, hereditary or immune-mediated
Neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome or botulism
Symptom-based presentations such as “pain in limb”, weakness, disturbance of skin sensation or paraesthesia when appropriate pre-test evaluations are inconclusive
Radiculopathy: cervical, lumbosacral
Plexopathy: idiopathic, traumatic, inflammatory or infiltrative
Myopathy: including polymyositis and dermatomyositis, myotonic disorders and congenital myopathies
Precise muscle location for injections such as botulinum toxin, phenol
Nerve conduction studies performed without needle electromyography (EMG) studies, unless contraindicated (e.g., individuals on anticoagulant therapy, hemophilia, Von Willibrand’s disease, idiopathic thrombocytopenic purpura [ITP], disseminated intravascular coagulation [DIC]), are considered investigational.
Automated (e.g. pre-configured) nerve conduction testing (e.g., NC-stat®, ADVANCE™, DPNCheck™) is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
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It is the position of the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) that electrodiagnostic (EDX) evaluations must be performed by physicians who have comprehensive knowledge of neurological and musculoskeletal disorders to assure accurate interpretation and diagnosis, and to provide Individuals with quality care. The typical EDX evaluation involves: a focused neuromuscular history and physical examination, the development of a differential diagnosis, the examination of muscles and nerves utilizing nerve conduction studies and needle electromyography, and the determination of a final diagnosis. The standard of care in clinical practice dictates that each of these components cannot be predetermined or standardized. Once the preliminary differential diagnosis has been determined, a technician may perform the nerve conduction studies (NCS) that were selected by the physician.
BCBST concurs with the position of AANEM that the physician performing EDX has received special training in the diagnosis and treatment of neurological and neuromuscular diseases and in the application of particular neurophysiologic techniques to the study of these disorders. This type of training is generally included in the residency or fellowship programs of physicians who specialize in physical medicine and rehabilitation (physiatrists) or neurology (neurologists). This specialized training is comprehensive including presentation of didactic materials by an experienced EDX consultant, a lengthy preceptorship under the supervision of an experienced EDX consultant, and the completion of a specified number of EDX evaluations (general 200 or more). BCBST does not recognize 2-3 day training courses (e.g. Vendor/manufacturer/distributor provided training, device specific training, week-end workshops, DVD training) as meeting the standards for specialized training in the field of EDX.
The technician performing NCS under the physician’s supervision, 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.
BCBST agrees with the current interpretation of the Committee on Electrodiagnosis of the American Chiropractic Association Council on Neurology that electrodiagnostic evaluation/interpretation in the assessment of neurological disorders should be performed by a board eligible or board certified Chiropractic Neurologist.
Published scientific evidence in peer-reviewed journals regarding the utilization of automated, non-invasive nerve conduction equipment for diagnosis of disease of the peripheral nervous system is lacking.
American Association of Electrodiagnostic Medicine. (2003, January). Consensus criteria for the diagnosis of multifocal motor neuropathy. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/afd29b39-2179-421e-bac7-f88b4294a27d/CCDiagoseMMN.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2014, August). Recommended policy for electrodiagnostic medicine. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/ed2143b6-917f-4218-b699-e682b18ad15d/2014_Recommended_Policy_EDX_Medicine-(1).pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2011, January). Position statement on neuromuscular medicine qualifications. Retrieved March 13, 2014 from http://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2016, January). Model policy for needle electromyography and nerve conduction studies. Retrieved September 15, 2016 from https://www.aanem.org/getmedia/65934187-d91e-4336-9f3c-50522449e565/Model-Policy.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2012). Who is qualified to practice electrodiagnostic medicine? Retrieved March 13, 2014 from http://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2015). Common indicators suggesting fraud & abuse in electrodiagnostic medicine. Retrieved September 14, 2016 from https://www.aanem.org.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2015). Mobile electrodiagnostic laboratories provide substandard patient care. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/21cc5d73-3d9f-4240-b780-5acd2f6eb15f/Position-Statement_Mobile-Electrodiagnostic-Laboratories.pdf.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2014). Proper performance and interpretation of electrodiagnostic studies. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/bd1642ce-ec01-4271-8097-81e6e5752042/Position-Statement_Proper-Performance-of-EDX_-2014.pdf.aspx.
American Association of Neuromuscular & Electrodiagnostic Medicine. (2014). Common referral indications for electrodiagnostic medicine evaluations. Retrieved September 14, 2016 from https://www.aanem.org/getmedia/d4fddaaa-58bc-491c-a7a9-cd006ae68ee5/Common-referral-indication.pdf.
American Chiropractic Association. (2014). ACA Neurology Council to offer accredited certification in electrodiagnostics. Retrieved March 14, 2014 from http://www.acatoday.org.
BlueCross BlueShield Association. Evidence Positioning System. (7:2019). Automated point-of-care nerve conduction tests (2.01.77). Retrieved September 18, 2019 from https://www.evidencepositioningsystem.com/. (17 articles and/or guidelines reviewed)
BlueCross BlueShield Association. Evidence Positioning System. (7:2019). Electromyography and nerve conduction studies. (2.01.95). Retrieved September 18, 2019 from https://www.evidencepositioningsystem.com/. (17 articles and/or guidelines reviewed)
CMS.gov: Centers for Medicare & Medicaid Services. Palmetto GBA. (2019, June). Nerve Conduction Studies and Electromyography. (LCD ID L34606). Retrieved September 18, 2019 from https://www.cms.gov.
Grigoriu, A.I., Dinomais, M., Rémy-Néris, O., & Brochard, S. (2015). Impact of injection-guiding techniques on the effectiveness of botulinum toxin for the treatment of focal spasticity and dystonia: a systematic review. Archives of Physical Medicine and Rehabilitation, 96 (11), 2067-2078. (Level 1 evidence)
Ploumis, A., Varvarousis, D., Konitsiotis, S., & Beris, A. (2014). Effectiveness of botulinum toxin injection with and without needle electromyographic guidance for the treatment of spasticity in hemiplegic patients: a randomized controlled trial. Disability and Rehabilitation, 36 (4), 313-318. Abstract retrieved September 15, 2016 from PubMed database.
U. S. Food and Drug Administration. (2003, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K070109. Retrieved September 21, 2010 from http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2003, May). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K060584. Retrieved September 21, 2010 from: http://www.accessdata.fda.gov.
U. S. Food and Drug Administration. (2011, March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K102610. Retrieved March 13. 2014 from http://www.accessdata.fda.gov.
Wu, C., Xue, F., Chang, W., Lian, Y., Zheng, Y., Xie,N., et al. (2016). Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia. SpringerPlus, 5, 1292. DOI 10.1186/s40064-016-2967-x. (Level 2 evidence)
ORIGINAL EFFECTIVE DATE: 4/1981
MOST RECENT REVIEW DATE: 11/14/2019
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