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Neurophysiologic Testing a nd Monitoring - …

N eur ophysiologic Testing a nd Monitor ing Page 1 of 22 UnitedHea lthca r e Commer cia l Medica l Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Commercial Med i ca l P ol i cy Neurophysiologic Testing and Monitoring Policy Number: 2021T0493Z Effective Date: January 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Applicable Codes .. 2 Description of Services .. 4 Clinical Evidence .. 6 Food and Drug Administration ..16 References ..18 Policy History/Revision Instructions for Use ..22 Coverage Rationale Nerve conduction Studies The following are proven and medically necessary: Nerve conduction studies with or without late responses ( , F-wave and H-reflex tests) and neuromuscular junction Testing when performed in conjunction with needle electromyography for any of the following known or suspected disorders: o Peripheral neuropathy/polyneuropathy ( , inherited, metabolic, traumatic, entrapment syndromes) o Plexopathy o Neuromuscular junction disorders ( , myasthenia gravis) o Myopathy o Motor neuron disease o Radiculopathy (cervical, thora cic or lumbosa cral) o Treatment guidance ()

nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to …

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1 N eur ophysiologic Testing a nd Monitor ing Page 1 of 22 UnitedHea lthca r e Commer cia l Medica l Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare Commercial Med i ca l P ol i cy Neurophysiologic Testing and Monitoring Policy Number: 2021T0493Z Effective Date: January 1, 2021 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Applicable Codes .. 2 Description of Services .. 4 Clinical Evidence .. 6 Food and Drug Administration ..16 References ..18 Policy History/Revision Instructions for Use ..22 Coverage Rationale Nerve conduction Studies The following are proven and medically necessary: Nerve conduction studies with or without late responses ( , F-wave and H-reflex tests) and neuromuscular junction Testing when performed in conjunction with needle electromyography for any of the following known or suspected disorders.

2 O Peripheral neuropathy/polyneuropathy ( , inherited, metabolic, traumatic, entrapment syndromes) o Plexopathy o Neuromuscular junction disorders ( , myasthenia gravis) o Myopathy o Motor neuron disease o Radiculopathy (cervical, thora cic or lumbosa cral) o Treatment guidance ( , muscle localization for botulinum toxin injections, when required to identify affected muscles warranting injection) Nerve conduction studies with or without late responses ( , F-wave and H-reflex tests) when performed without needle electromyography for individuals who have any of the above known or suspected disorders with any of the following clinical indications: o Individuals treated with anticoagulants; or o Individuals with lymphedema; or o Individuals being evaluated for carpal tunnel syndrome The following are unproven and not medically necessary due to insufficient evidence of efficacy: Nerve conduction studies for all conditions other than those listed above as proven.

3 Non-invasive automatic, portable, or automated point of care nerve conduction Monitoring systems ( , the NC-stat System, the Brevio NCS-Monitor, and the Advance System) that test only distal motor latencies and conduction velocities for the purpose of electrodiagnostic Testing . Other Neurophysiological Testing The following are unproven and not medically necessary due to insufficient evidence of efficacy: Surface electromyography (SEMG) Community Plan Policy Neurophysiologic Testing and Monitoring Medicare Advantage Coverage Summary Neurophysiological Studies N eur ophysiologic Testing a nd Monitor ing Page 2 of 22 UnitedHea lthca r e Commer cia l Medica l Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. SEMG based seizure Monitoring systems Macroelectromyography (macro-EMG) Testing Physiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopes Quantitative sensory Testing , including monofilament Testing , pressure-specified sensory Testing , computer assisted sensory examinations, and current perception threshold (CPT) Testing Visual evoked potential Testing for diagnosing and evaluating glaucoma This policy does not address intraoperative Neurophysiologic Testing .

4 Applicable Codes The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. CPT Code Description 0106T Quantitative sensory Testing (QST), Testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation 0107T Quantitative sensory Testing (QST), Testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation 0108T Quantitative sensory Testing (QST), Testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia 0109T Quantitative sensory Testing (QST), Testing and interpretation per extremity; using heat-pa in stimuli to assess small nerve fiber sensation and hyperalgesia 0110T Quantitative sensory Testing (QST), Testing and interpretation per extremity.

5 Using other stimuli to assess sensation 0464T Visual evoked potential, Testing for glaucoma, with interpretation and report 0533T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; includes set-up, patient training, configuration of monitor, data upload, analysis and initial report configuration, download review, interpretation and report 0534T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; set-up, patient training, configuration of monitor 0535T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; data upload, analysis and initial report configuration 0536T Continuous recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor for 6 days up to 10 days; download review, interpretation and report 95860 Needle electromyography; 1 extremity with or without related paraspinal areas 95861 Needle electromyography; 2 extremities with or without related paraspinal areas 95863 Needle electromyography; 3 extremities with or without related paraspinal areas 95864 Needle electromyography; 4 extremities with or without related paraspinal areas 95865 Needle electromyography; larynx 95866 Needle electromyography; hemidiaphragm 95867 Needle electromyography; cranial nerve supplied muscle(s), unilateral 95868 Needle electromyography.

6 Cranial nerve supplied muscles, bilateral 95869 Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12) N eur ophysiologic Testing a nd Monitor ing Page 3 of 22 UnitedHea lthca r e Commer cia l Medica l Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. CPT Code Description 95870 Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 95872 Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied 95873 Electrical stimulation for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) 95874 Needle electromyography for guidance in conjunction with chemodenervation (List separately in addition to code for primary procedure) 95885 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction , amplitude and latency/velocity study.

7 Limited (List separately in addition to code for primary procedure) 95886 Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction , amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 95887 Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction , amplitude and latency/velocity study (List separately in addition to code for primary procedure) 95905 Motor and/or sensory nerve conduction , using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report 95907 Nerve conduction studies; 1-2 studies 95908 Nerve conduction studies; 3-4 studies 95909 Nerve conduction studies; 5-6 studies 95910 Nerve conduction studies; 7-8 studies 95911 Nerve conduction studies; 9-10 studies 95912 Nerve conduction studies.

8 11-12 studies 95913 Nerve conduction studies; 13 or more studies 95937 Neuromuscular junction Testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 95999 Unlisted neurological or neuromuscular diagnostic procedure 96002 Dynamic surface electromyography, during walking or other functional activities, 1-12 muscles 96003 Dynamic fine wire electromyography, during walking or other functional activities, 1 muscle 96004 Review and interpretation by physician or other qualified health care professional of comprehensive computer-based motion analysis, dynamic plantar pressure measurements, dynamic surface electromyography during walking or other functional activities, and dynamic fine wire electromyography, with written report CPT is a registered trademark of the American Medical Association HCPCS Code Description A9279 Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics.

9 Not otherwise classified A9280 Alert or alarm device, not otherwise classified G0255 Current perception threshold/sensory nerve conduction test, (SNCT) per limb, any nerve S3900 Surface electromyography (EMG) N eur ophysiologic Testing a nd Monitor ing Page 4 of 22 UnitedHea lthca r e Commer cia l Medica l Policy Effective 01/01/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Description of Services Neurophysiologic studies are used to evaluate and monitor individuals with suspected or known central and peripheral nervous system disorders. This policy includes information on the following tests: Electromyography (EMG) EMG measures muscle response to electrical or nerve stimulation. The test is used to evaluate the function of individual nerves and muscles and has various applications in sports, ergonomics, rehabilitation, orthopedics, psychology, and neurology.

10 Two main types of EMG exist: needle EMG (NEMG) and surface EMG (SEMG). SEMG is a diagnostic technique in which electrodes are placed on the skin and used to measure the electrical activity of the underlying muscle in response to electrical or nerve stimulation. The SEMG recordings, also referred to as the electromyogram can potentially be used to detect impairments in nerve and/or muscle function. Paraspinal EMG is a type of surface EMG that is used to evaluate back pain. SEMG based seizure Monitoring systems such as the SPEAC S y st em ( Bra i n Sentinel Seizure Monitoring and Alerting System) is a non-invasive monitor that is placed on the biceps muscles to analyze surface electromyography (SEMG) signals that may be associated with generalized tonic-clonic (GTC) seizures. The system provides an alarm to alert caregivers of a possible GTC seizure.


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