Nerve Conduction Studies and Electromyography

Jurisdiction: JH MAC Part B. States: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas. Type: Active LCD

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Electrodiagnostic (EDX) studies are an extension of a clinical assessment for evaluation of an assortment of focal and generalized neuromuscular disorders of the peripheral nervous system and the central nervous system. Assessment of these disorders generally includes a focused neuromuscular history and physical examination, the development of a differential diagnosis and EDX studies. The EDX studies are founded on the history and physical and suspected diagnosis and are followed by an assessment of muscles and nerves using nerve conduction studies (NCSs) and needle electromyography (NEMG), and the determination of a final diagnosis. The NCSs are performed and interpreted with the NEMG on site and in real time. 1-2 NCSs may be conducted without NEMG in some situations, such as entrapment neuropathies, but this should be the exception rather than the normal practice pattern. When NCSs are conducted without NEMG, beneficial data that may be important in determining an accurate diagnosis are commonly missing. The results of the NEMG studies can frequently provide an alternative etiology or coexisting disorder in the case of a suspected disorder. 1,3 EDX studies provide beneficial information regarding location, chronicity, severity, and pathophysiology to help determine a diagnosis and monitor a disease process in response to therapy. 1 Covered Indications NCSs and NEMG are considered medically reasonable and necessary when they are performed and interpreted at the same time, on site, and in real time for any of the following circumstances: Plexopathy - including idiopathic, traumatic, inflammatory or infiltrative, radiation-induced, 1 brachial plexopathies (e.g., neuralgic amyotrophy, thoracic outlet syndrome), and lumbosacral plexopathies (e.g., diabetic, non-diabetic lumbosacral radiculoplexus neuropathy) 4 Focal neuropathies (e.g., entrapment neuropathies or compressive lesions/syndromes such as carpal tunnel syndrome, 5-8 ulnar neuropathy, 9-10 tarsal tunnel syndrome, 11 femoral neuropathy, saphenous neuropathy, lateral femoral cutaneous neuropathy, peroneal (fibular) neuropathy, tibial neuropathies, sciatic neuropathy) 1,12-18 Generalized neuropathies such as metabolic (e.g., diabetic, uremic), toxic, hereditary or immune-mediated 1,19-20 Motor neuron disease (e.g., amyotrophic lateral sclerosis [ALS] or Lou Gehrig’s disease) 1,21-22 Myopathy - including inflammatory myopathies such as polymyositis and dermatomyositis, congenital myopathies, 23 congenital and hereditary dystrophic and nondystrophic myopathies, including myotonic muscular dystrophy, acquired myopathies (drug induced myopathy associated with statins, thyroid related), metabolic myopathies (e.g., McArdle disease) 1,24 Myotonic disorders (e.g., drug induced myotonia) 25 Neuromuscular junction disorders (e.g., myasthenia gravis, Lambert-Eaton myasthenic syndrome, botulism) 1,26-27 Polyneuropathies 1,28-30 Radiculopathy - cervical, 31 thoracic or lumbosacral 1,32-33 Spinal cord disorders 31 (i.e., myelopathy) Symptom-based presentations such as “pain in limb”, weakness, cramping/twitching, disturbance of skin sensation or “paresthesia” when appropriate pre-test evaluations are inconclusive, and the clinical assessment unequivocally supports the need for the study 1 Traumatic nerve lesions, for diagnosis and prognosis 1 Neuromuscular Junction (NMJ) Testing is considered medically reasonable and necessary for any of the following conditions: Botulinum toxicity 1,3 Motor neuron disease (e.g., ALS or Lou Gehrig’s disease) 1 Myopathy 1,34 Myasthenia gravis 27,34-35 Myasthenic syndrome (e.g., Lambert-Eaton myasthenic syndrome) 1,3 NCSs when performed without NEMG are considered medically reasonable and necessary for the following situations: Individuals treated with anticoagulants 35-36 such as warfarin (Coumadin), rivaroxaban (Xarelto), dabigatran (Pradaxa), apixaban (Eliquis), edoxaban (Lixiana), clopidogrel (Plavix), ticagrelor (Brilinta), ticlopidine (Ticlid), prasugrel (Effient), varapaxar (Zontivity), dipyridamole, cilostazol (Pletal) Individuals with significant lymphedema in the affected extremity 36 Individuals being evaluated for carpal tunnel syndrome or tarsal tunnel syndrome 3,11 NEMG when performed without NCSs is considered medically reasonable and necessary for the following situations: Guidance for botulinum toxin treatment injections when it is difficult to isolate affected muscles 1,37 Laryngeal neuropathy 38 Constipation 39 Fecal incontinence 39 Lower urinary tract symptoms 40-42 Patients with risk factors for urinary retention 40-44 Single Fiber Electromyography (SFEMG) is considered medically reasonable and necessary for the following condition: Ocular myasthenia 45 Myasthenia gravis 27,34-35 Myasthenic syndrome (e.g., Lambert-Eaton myasthenic syndrome) 27 Limitations The following are considered not medically reasonable and necessary: EDX studies where the interpretation is delayed and not completed at the time the study is performed 2, 8,46 The NCS must be performed and interpreted with the NEMG on site and in real time 1-2 EDX studies (NCS and NEMG) not performed in accordance with the CMS regulations defined for supervision for diagnostic tests (Refer to the CMS IOM Pub 100-02, Medicare Benefit Policy Manual , Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests) Non-invasive EDX studies using portable hand-held devices or automated point of care nerve conduction monitoring systems, which are incapable of real-time waveform display and analysis 3,47-53 Testing for polyneuropathy of diabetes in patients without clinical deficits or for the sole purpose of monitoring disease intensity or treatment efficacy 3 Quantitative Sensory Testing (QST) (e.g., hot-cold, touch, vibration) 54-58 NCSs accomplished with discriminatory devices that use fixed anatomic templates and computer-generated reports used as an adjunct to physical examination routinely on all patients 1 Physiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopes 59 NCSs or EMG for muscle pain without the presence of other abnormalities on examination or in laboratory testing 60 NEMG for the following situations: Definitive diagnosis based on paraspinal NEMG in areas with scar from past surgeries (e.g., previous laminectomies) 3 Surface electromyography (SEMG) 3,61-63 Macroelectromyography (macro-EMG) 3 NEMG for isolated neck or back pain after a motor vehicle accident 60 Studies performed beyond the reasonable maximum number of studies recommended in the American Medical Association (AMA) Current Procedural Terminology (CPT ® ) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves. These recommendations are supported by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). 1 Additional studies may be considered upon redetermination. Please refer to the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs) for additional limitations. Repeat EDX assessment may be needed in certain circumstances. The frequency for repeating EDX studies in a given patient by a given EDX provider for a given diagnosis per year can be reasonably limited. The following number of studies per 12-month period per diagnosis per provider are suitable: 1) Two studies for carpal tunnel-unilateral, carpal tunnel-bilateral, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and NMJ disorders. 2) Three studies for motor neuron disease and plexopathy. These limits should not apply if the patient requires assessment by more than one EDX provider (i.e., a second opinion or an expert opinion at a tertiary care center) in a given year or if the patient requires evaluation for a second diagnosis in a given year. 1 Repeat EDX studies are rare and should not be necessary in a 12-month period in 80% of all cases. 1 Additional studies may be considered upon redetermination. In such circumstances, the rationale for the repeat study should be included in the medical record. Comparison with the previous study findings should be documented. Provider Qualifications Services will be considered medically reasonable and necessary when all aspects of care are within the scope of practice of the provider’s professional licensure, when performed according to the supervision requirements per state scope of practice laws, and when all procedures are performed by appropriately trained providers in the appropriate setting. Notice : Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, 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.