Nerve Conduction Studies Sep 15 1 National Medical Policy Subject: Nerve Conduction Studies Policy Number: NMP237 Effective Date*: September 2005 Updated: September 2015 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation X Local Coverage Determination (LCD)* Nerve Conduction Studies (NCS) and Electromyography (EMG); Nervous System Studies - Autonomic Function: http://www.cms.gov/medicare-coverage- database/search/advanced-search.aspx Article (Local)* X Other MLN Matters Number: MM3339. June 18, 2004. Updated April 5, 2013 NCD: Sensory Nerve Conduction Threshold Test: http://www.cms.gov/Outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM3339.pdf CMS Manual System. Department of Health & Human Services (DHHS). Pub. 100-03 Medicare National Coverage Determinations. Transmittal 15. 2004: https://www.cms.gov/Regulations- and- Guidance/Guidance/Transmittals/downloads/r10 ncd.pdf
Transcript
Nerve Conduction Studies Sep 15 1
National Medical Policy Subject: Nerve Conduction Studies
Policy Number: NMP237
Effective Date*: September 2005
Updated: September 2015
This National Medical Policy is subject to the terms in the
IMPORTANT NOTICE
at the end of this document
For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for
coverage guidelines prior to applying Health Net Medical Policies
The Centers for Medicare & Medicaid Services (CMS)
For Medicare Advantage members please refer to the following for coverage
guidelines first:
Use Source Reference/Website Link
National Coverage Determination
(NCD)
National Coverage Manual Citation
X Local Coverage Determination
(LCD)*
Nerve Conduction Studies (NCS) and
Electromyography (EMG); Nervous System
Studies - Autonomic Function:
http://www.cms.gov/medicare-coverage-
database/search/advanced-search.aspx
Article (Local)*
X Other MLN Matters Number: MM3339. June 18, 2004.
and needle electromyography (EMG), typically performed together, and by a trained
practitioner continue to be considered the gold standard of electrodiagnostic testing.
Both NCVs and EMGs are used for a clinical diagnosis of peripheral nervous system
disorders.
Asad et al. (2010) compared the nerve conduction studies in clinically undetectable
and detectable sensorimotor polyneuropathy in type 2 diabetics. Diagnosed diabetics
(n = 60) were divided in two groups. Group 1 (n1 = 30) with clinically undetectable
and group 2 (n2 = 30) with clinically detectable Diabetic Polyneuropathy. Detection
of the sensorimotor neuropathy was done according to Diabetic Neuropathy
Symptom Score and Diabetic Neuropathy Examination scores. The simplified nerve
conduction studies protocol was followed in recording amplitudes, velocities and
latencies of minimum two (Sural, Peroneal) and maximum six i.e. three sensory
(Sural, Ulnar, Median) and three motor (Peroneal, Ulnar, Tibial) nerves. The
comparisons were done between different parameters of nerve conduction studies
with the neurological scores in undetectable and detectable groups using Pearson's
chi square test. The amplitudes, velocities, latencies, outcome and grading of
Nerve Conduction Studies Sep 15 15
neuropathy in nerve conduction studies when compared with neurological detection
scores showed a significant relation in each group regarding evaluation (p = 0.005, p
= 0.004, p = 0.05, p = 0.00001, p = 0.003 respectively). Diabetic Neuropathy
Symptom Score and Diabetic Neuropathy Examination Score together can help in
prompt evaluation of the diabetic sensorimotor polyneuropathy though nerve
conduction study is more powerful test and can help in diagnosing subclinical cases.
Scientific Rationale – Update February 2009 (2007) The American Medical Association notes: “Utilization of motor or sensory
nerve conduction velocity studies at a frequency of 2 sessions per year would be
considered appropriate for most conditions (e.g., unilateral or bilateral carpal tunnel
syndrome, radiculopathy, mononeuropathy, polyneuropathy, myopathy, and
neuromuscular junction disorders).”
(2006) The American Association of Neuromuscular & Electrodiagnostic Medicine
(AANEM) states, “The performance of or interpretation of NCS separately from the
needle EMG component of the testing should clearly be the exception. Nerve
conduction studies performed independent of needle EMG may only provide a portion
of the information needed to diagnose muscle, nerve root, and most nerve disorders.
When the NCS is used on its own without integrating needle EMG findings, or when
an individual relies solely on a review of NCS data, the results can be misleading and
important diagnoses may be missed. Moreover, individuals who interpret NCV data
without patient interaction or who rely on studies that have delayed interpretation,
who have interpretation made off-site, and who interpret results without
complementary information obtained from EMG studies are not meeting the
standards outlined in the AANEM policy recommendations.”
Except in limited clinical situations, evidence in the published, peer-reviewed
scientific literature, textbooks and statements by the AANEM indicates that both
nerve conduction studies (NCS) and needle electromyography (NEMG) are required
to diagnose peripheral nervous system disorders. Circumstances under which NCS
and EMG should not be performed together include, but are not limited to, limited
follow-up studies of neuromuscular structures that have undergone previous
electrodiagnostic evaluation, the current use of anticoagulants, the presence of
lymphedema, or when a patient cannot tolerate the needle EMG procedure. In
addition, the AANEM indicates that for suspected carpal tunnel syndrome, the extent
of the needle EMG examination depends on the results of the NCSs and the
differential diagnosis considered for the individual patient (AANEM, 2004).
The table below summarizes the recommendations of the AANEM regarding the
reasonable maximum number of studies per diagnostic category necessary for a
physician to arrive at a diagnosis for 90% of patients with that final diagnosis
(AANEM, 2004).
Number of Services Recommended by the American Association of
Neuromuscular & Electrodiagnostic Medicine (AANEM):
Nerve Conduction Studies Sep 15 16
Nerve Conduction
Studies
Other EMG Studies
Indications Needle
EMG
Motor
NCV
studies
with
and/or
without
F-wave
Sensory
NCV
studies
H-
Reflex
Neuromuscular
Junction Testing
(Repetitive
Stimulation)
Carpal tunnel (unilateral) 1 3 4 -- --
Carpal tunnel (bilateral) 2 4 4 -- --
Radiculopathy 2 3 2 2 --
Mononeuropathy 1 3 3 2 --
Polyneuropathy/Mononeuropathy
Multiplex
3 4 4 2 --
Myopathy 2 2 2 -- 2
Motor Neuropathy 4 4 2 -- 2
Plexopathy 2 4 6 2 --
Neuromuscular junction 2 2 2 -- 3
Tarsal tunnel syndrome
(unilateral)
1 4 4 -- --
Tarsal tunnel syndrome
(bilateral)
2 5 6 -- --
Weakness, fatigue, cramps, or
twitching (focal)
2 3 4 -- 2
Weakness, fatigue, cramps, or
twitching (general)
4 4 4 -- 2
Pain, numbness, or tingling
(unilateral)
1 3 4 2 --
Pain, numbness, or tingling
(bilateral)
2 4 6 2 --
Nerve Conduction Studies Sep 15 17
Devices
Katz (2006) established a normal data set for median nerve studies in industrial
workers using NC-stat technology. A total of 1695 individuals applying for
employment at a single heavy industry plant without symptoms of carpal tunnel
syndrome (CTS) were studied. Values for median distal motor latency (DML),
amplitude, and F-waves were recorded in the dominant limbs. The DML was 3.81 +/-
0.57 milliseconds, with a 95 % cut-off value of 4.75 milliseconds. Amplitude of the
compound muscle action potential was 0.95 +/- 0.46 mV, reflecting the use of
volume conduction by this technology. Most of the workers who were characterized
as having borderline, prolonged, or very prolonged distal motor latencies according
to NeuroMetrix automated report actually fell below the 95 % cut-off of this
independent data analysis. The author concluded that the NC-stat technology using
DML appears to be no more sensitive or specific than a traditionally performed DML
for the diagnosis of CTS. Until recently promoted sensory studies using NC-stat
technology are better defined, this technology cannot be recommended for screening
or diagnosis of CTS in an industrial population.
(2006) The American Association of Neuromuscular & Electrodiagnostic Medicine
(AANEM), states that “The standard of care in clinical practice dictates that using a
predetermined or standardized battery of NCSs for all patients is inappropriate.” “It
is the position of the AANEM that, except in unique situations, NCSs and needle EMG
should be performed together in a study design determined by a trained
neuromuscular physician.” The AANEM explained that standardized nerve conduction
studies performed independent of needle EMG studies may miss data essential for an
accurate diagnosis.
The American Academy of Neurology (AAN), and the American Academy of Physical
Medicine and Rehabilitation (AAPM&R) indicate that "Testing should be performed
using EDX (electrodiagnostic medicine) equipment that provides assessment of all
parameters of the recorded signals.”
There is insufficient evidence to demonstrate equivalence or superiority of portable
hand held automated devices, such as the NC-stat device or the Brevio NCS-Monitor,
in comparison to conventional electrodiagnostic testing methods. The studies that
were found are primarily case series, (Elkowitz et al. [2005], Kong et al. [2006],
Vinik et al. [2004], Loeffler et al. [2000]). There are no randomized, controlled
studies available to compare the NC-Stat device or the Brevio NCS –Monitor to the
current and convention electrodiagnostic testing that is done on symptomatic
patients. Some of the studies were funded and /or written by employees of
NeuroMetrix, the manufacturer of NC-Stat, which would reflect bias. The available
evidence and diagnostic accuracy for these devices is limited in comparison with
standard nerve conduction velocity studies and needle electromyography, which are
considered the gold-standard testing methods. Larger independent studies would be
needed to demonstrate the equivalence of NC-stat to traditional NCS in nerve
conduction testing and the diagnoses of neuropathies. In addition, per the evidence-
based guidelines, EMG studies should be available in the majority of cases, at the
same time as the NCS, to enable a reliable diagnosis.
Scientific Rationale – Update November 2008 Measurement of nerve conduction speed is commonly performed to aid in the
diagnosis of various disorders affecting the nerves of the upper extremities such as
diabetic neuropathy (DN) and carpal tunnel syndrome (CTS). Diseased or damaged
Nerve Conduction Studies Sep 15 18
nerves show decreased conduction speed or smaller-sized electrical signals. These
are detected by stimulating the nerve with an electrode placed on the skin and
capturing the time it takes for the nerve impulse to travel to a recording electrode.
These types of nerve conduction studies (NCS) are traditionally carried out by a
neurologist or other specialist in a specialized electromyographic laboratory, where
other procedures such as electromyography (EMG; recording electrical activity
directly within muscles through needle electrodes) are often necessary for diagnosis.
A comprehensive diagnosis also relies on a variety of physical examinations, and may also involve imaging.
Some examples of the automated nerve conduction studies (NCS) using hand held
units being used without EMG's include the NC-Stat Monitor, the Brevio NCS-Monitor
and the Neural-Scan Nerve Conduction Study sensory (NCSs) exam. A description of
these devices is listed below:
The NC-Stat Monitor (NeuroMetrix Inc.) is an automated handheld device using
proprietary technology for conducting NCS. The available evidence for the NC-
stat monitor is limited in comparison with standard nerve conduction velocity
studies and needle electromyography. NC-stat technology using distal motor
latency (DML) appears to be no more sensitive or specific than a traditionally
performed DML for the diagnosis of carpal tunnel syndrome.
The Brevio NCS-Monitor (NeuMed Inc.) is a hand-held automated device
designed to assess peripheral nerves for conditions such as carpal tunnel
syndrome, diabetic peripheral neuropathy, and tarsal tunnel syndrome. There is
insufficient evidence to establish the clinical value of this automated NCV studies
device. This is not FDA approved.
The Neural-Scan Nerve Conduction Study sensory (NCSs) exam helps to
diagnose severity, location & distribution of radiculopathy or neuropathy. Non-
invasive method. Measures sensory threshold using neuroselective frequency to
test Type A-delta fibers. Abnormally high NCS measures indicate significant
nerve conduction loss. Abnormally low NCS indicate hyperesthetic state that
corresponds with inflamed, irritated or regenerating nerves. This is not FDA
approved.
(2006) The American Association of Neuromuscular & Electrodiagnostic Medicine
(AANEM) has developed the following position statement in response to inquiries
about: (1) physicians interpreting NCS data without any direct patient contact and
without providing direct oversight over the performance of nerve conduction studies
(NCSs); and (2) NCSs being utilized to diagnose patients without a complementary
needle electromyography (EMG) study. The AANEM believes that electrodiagnostic
studies should be performed by physicians properly trained in electrodiagnostic
medicine, that interpretation of NCS data alone absent face-to-face patient
interaction and control over the process provides substandard care, and that the
performance of NCSs without needle EMG has the potential of compromising patient
care. It is the AANEM’s opinion that it is in the best interest of patients, in the
majority of situations, for the needle EMG and the NCS examination to be conducted
and interpreted at the same time.
Nerve Conduction Studies Sep 15 19
Standard Nerve Conduction Velocity
Testing
Automated Nerve Testing
Systems
Includes safeguards and procedures to
assure proper performance and
interpretation.
Many of the safeguards used with
standard nerve conduction studies are
not used
in these systems.
Involves electrical stimulation of
peripheral nerves, and recording of
electrical responses from the same
peripheral nerve or from a muscle.
Similar to standard nerve conduction
velocity testing in that both involve
electrical stimulation of peripheral
nerves, and recording of electrical
responses from
the same peripheral nerve or from a
muscle. However, these devices have
a number of differences with standard
nerve conduction velocity tests.
The physician specialist and a registered
technologist perform the testing.
Done in the office by office staff
Velocity tests can stimulate and record
both proximally and distally.
Only several specific nerves can be
tested.
Orthodromic and antidromic conduction
is available.
Only one direction of conduction is
available.
The technique of standard nerve
conduction velocity tests varies
according to the patient's situation.
A single specific technique is
predetermined.
EMG is always available. EMG is generally not available at the
point of service.
Standard nerve conduction velocity
testing, stimulator and recording sites
can be moved around to find optimal
locations.
Stimulator and recording sites are
placed at
predetermined anatomic locations
with automated devices.
The clinician assesses latencies,
amplitudes, configurations, and
conduction velocities. The clinician
critiques tracings, and determines if
repeat recordings needed. The clinician
takes into account the patient’s history,
physical, nerve conduction velocities
and EMG as needed when interpreting
the results. The clinician also considers
normal variants.
By contrast, a computer scores
amplitudes and latencies, and
determines if tests are normal
according to a look-up table. The
computer prints an automated
interpretation statement for the
physician to sign; the computer’s
statement is taken from a
programmed list of statements.
Test preset nerves only.
Nerve Conduction Studies Sep 15 20
Standard Nerve Conduction Velocity
Testing
Automated Nerve Testing
Systems
A trained clinician scores peaks,
latencies, determines if tests are
normal, adjusted to clinically relevant
factors. The clinician assesses latencies,
amplitudes, configurations, and
conduction velocities. The clinician
critiques tracings, and determines if
repeat recordings needed. The clinician
takes into account the patient’s history,
physical, nerve conduction velocities
and EMG as needed when interpreting
the results. The clinician also considers
normal variants.
A computer scores amplitudes and
latencies, and determines if tests are
normal according to a look-up table.
The computer prints an automated
interpretation statement for the
physician to sign; the computer’s
statement is taken from a
programmed list of statements.
Velocity testing, stimulator and
recording sites can be moved around to
find optimal locations.
Stimulator and recording sites are
placed at predetermined anatomic
locations.
(2008) No studies were identified that addressed the utility of automated nerve
conduction tests in a clinical setting. Particularly needed are data on the sensitivity
and specificity of automated nerve conduction tests performed at the point-of-care in
comparison with the “gold standard” of laboratory EMG. Overall, evidence remains
insufficient to evaluate the effect of point-of-care automated nerve conduction tests
on health outcomes.
Scientific Rationale – Update June 2007 The ‘NC-stat System’ (NeuroMetrix Inc.) is a portable, hand-held, noninvasive,
automated nerve conduction-testing device that has been marketed for use in an
office or clinic setting. The device was originally approved for testing of motor
conduction in the median and ulnar nerves in the wrist; approval was subsequently
expanded to include sensory testing in the wrist as well as for NCS in the lower
limbs. The purpose of the NC-stat System is to assist in the diagnosis of peripheral nerve disorders, such as carpal tunnel syndrome and diabetic peripheral neuropathy.
This device consists of four components which include single-use biosensors, a
battery powered monitor that connects to the sensors and stores information, a
docking station for the monitor, and the on Call™ Information System, (which is a
remote report generation system to which test data are transmitted for analysis). A
computerized system interprets the data, which is capable of being transmitted to
the treating physician within minutes.
The NC-stat System received FDA approval in 1998, through the 510(k) approval
process, for measurement of neuromuscular signals that are useful in diagnosing and
evaluating systemic and entrapment neuropathies. This original approval was for use
as an adjunct to, and not as a replacement for, conventional electrodiagnostic
testing.
In an updated position statement on the proper performance and interpretation of
electrodiagnostic studies from the American Association of Neuromuscular and
Electrodiagnostic Medicine (AANEM, 2006), although no specific reference to
portable, automated nerve conduction testing devices, (i.e., the NC-stat device) is
made, the following comments were noted:
Nerve Conduction Studies Sep 15 21
1. Nerve conduction studies performed independent of needle electromyography
(EMG) may only provide a portion of the information needed to diagnose
muscle, nerve root, and most nerve disorders;
2. When the nerve conduction study (NCS) is used on its own without
integrating needle EMG findings or when an individual relies solely on a
review of NCS data, the results can be misleading, and important diagnoses
may be missed;
3. Individuals without medical education in neuromuscular disorders and without
special training in electrodiagnostic procedures typically are not qualified to
interpret the waveforms generated by NCS and needle EMG or to correlate
the findings with other clinical information to reach a diagnosis.
In 2005, the Washington State Department of Labor and Industries conducted a
technology assessment of the NC-stat System to evaluate the available peer-
reviewed literature on this device, following inquiries from physicians in the local
practice community, as well as from staff of the Department of Labor and Industries.
This technology assessment reviewed results from six articles in May of 2005, and an
additional two articles were reviewed in 2006 to update the review. The report
concluded that the NC-stat System is not equivalent to conventional methods for nerve conduction velocity testing (Morse, 2006).
To date, there has been very limited published evidence to demonstrate the safety
and efficacy of automated, noninvasive nerve conduction testing devices, such as the
NC-stat device, as compared to conventional “Gold standard” electrodiagnostic
testing using needle electromyography (EMG) and nerve conduction velocity studies (NCS).
There is little evidence evaluating the efficacy of the NC-stat and most of the
published clinical studies have only evaluated use of the device for assessment of median and ulnar nerves (Katz, 2006; Kong, 2006).
Katz et al (2006) have reported Nc-stat is no more sensitive or specific than a
traditionally performed distal motor latency for the diagnosis of carpal tunnel
syndrome. In addition, the diagnostic accuracy for other conditions involving the lower extremities has not been demonstrated.
Most of the published literature on the NC-stat device, involved unblinded
assessments where persons affiliated with the manufacturer were principal
investigators or co-authors (Leffler et al, 2000; Vinik et al, 2004; Kong et al, 2006;
Megerian and Gozani, 2006). Larger, independent, controlled studies would be
needed to demonstrate the equivalence of NC-stat to traditional NCS in nerve
conduction testing and the diagnoses of neuropathies; data from these trials are
needed to demonstrate its safety and efficacy in the long-term.
Scientific Rationale - Initial Nerve Conduction Studies (NCS), or Nerve Conduction Velocity (NCV), is a test of the
speed of conduction of impulses through a nerve. They measure action potentials
resulting from peripheral nerve stimulation recordable over the nerve or from an
innervated muscle. The nerve is stimulated, usually with surface electrodes, which
are patch-like electrodes (similar to those used for ECG) placed on the skin over the
nerve at various locations. One electrode stimulates the nerve with a very mild
Nerve Conduction Studies Sep 15 22
electrical impulse. The resulting electrical activity is recorded by the other electrodes.
The distance between electrodes and the time it takes for electrical impulses to
travel between electrodes are used to calculate the nerve conduction velocity. Often
the nerve conduction test is followed by electromyography (EMG) which involves
needles being placed into the muscle and asking the patient to contract that muscle.
Nerve conduction studies are typically performed together with electromyography
(EMG). EMG is often used to encompass a NCS.
Results of this test reflect on the integrity and function of: (1) the myelin sheath
(Schwann cell-derived insulation covering an axon); and (2) the axon (an extension
of neuronal cell body) of a nerve. Most often, abnormal results are caused by some
sort of neuropathy (nerve damage or destruction) including: (1) demyelination
(destruction of the myelin sheath); (2) conduction block (the impulse is blocked
somewhere along the nerve pathway); or (3) axonopathy (damage to the nerve
axon). Any peripheral neuropathy can cause abnormal results, as can damage to the
spinal cord and disc herniation (herniated nucleus pulposus) with nerve root
compression. A NCV test shows the condition of the best surviving nerve fibers and
may remain normal if even a few fibers are unaffected by a disease process. A
normal NCV test result can occur despite extensive nerve damage.
Nerve conduction studies (NCS) are of two broad types: sensory and motor. Either
surface or needle electrodes can be used to stimulate the nerve or record the
response. Axonal damage or dysfunction generally results in loss of nerve or muscle
potential amplitude; whereas, demyelination leads to prolongation of conduction
time. It is often valuable to test conduction status in proximal segments of peripheral
nerves. These segments include the first several centimeters of a compound nerve
emerging from the spinal cord or brainstem. H-reflex, F- waves, and Blink reflex
testing accomplish this task better than distal NCS.
Sensory conduction studies are done by initiating an electrical stimulation from the
skin's surface to a nerve site. As the impulse travels along the nerve pathway, the
conduction characteristics of the impulse are recorded and assessed. The parameters
measured consist of: (1) amplitude (the size of the waveform on the graph); (2)
latency (the length of time the impulse takes to make a waveform change); and (3)
conduction velocity (usually a calculated measurement). Motor conduction studies
are accomplished by applying skin surface stimulation to various points along the
course of a motor nerve while recording from its attached muscle or the muscle
supplied by it. Tracings of the muscle's reaction to the electrical stimulation are
recorded and assessed. The parameters measured are the same as sensory
conduction studies, and these tests are commonly performed together.
F-waves are confined to the motor pathways. The number of F-wave tests performed
are dependent on the previous electrodiagnostic findings. Bilateral testing is used for
comparison purposes. H-reflexes are studies that provide an evaluation of the
proximal (closer to the spine) portion of the nerve. The H-reflex measures both
sensory and motor pathways. The parameters measured are oriented to the latency
of responses. H-reflex studies may be performed bilaterally in response to abnormal
pathology in the symptomatic limb. It is covered when done with the motor
conduction test. Diagnoses covered are those associated with lumbar
radiculopathy/plexopathy, cervical or brachial neuropathy or demyelinating
myelopathy. Neuromuscular junction testing consists of obtaining a direct motor
response, then repeating the impulses to the same nerves at various frequencies and
before and after enervation. The blink reflex study evaluates conduction from the
Nerve Conduction Studies Sep 15 23
proximal facial nerves and brainstem. Visual-evoked potential (VEP) testing central
nervous system, checkerboard of flash. This test is generally used to show latency
changes in demyelinating conditions and amplitude changes in axonal loss.
Review History September 2005 Medical Advisory Council Initial Approval
June 2007 Nc-Stat System (NeuroMetrix Inc.) added to policy as
investigational and therefore not medically necessary, due to
inadequate scientific evidence in the peer-reviewed medical
literature to support its safety and efficacy
November 2008 Updated policy. No changes. Codes reviewed.
February 2009 Update. Added local Medicare criteria in which NCS done without
EMG is covered in specific areas, with criteria. At times, local
Medicare covers NC Stat. Added criteria for NCVS done alone
without EMG.
March 2011 Update. Added Medicare Table with link to LCD. No revisions.
December 2011 Update. No revisions.
September 2012 Update – Added surface electromyography (EMG) as a diagnostic
tool for the evaluation of patients with neuromuscular diseases and
low back pain as investigational.
September 2013 Update. Added to the policy statement criteria #6-10 as medically
necessary. These criteria are already represented in the list of
medically necessary indications in the policy statement. Code
updates.
September 2014 Update. No revisions. Code updates.
September 2015 Update. No revisions. Code updates.
This policy is based on the following evidence-based guidelines: 1. American Association of Neuromuscular & Electrodiagnostic Medicine / American
Academy of Neurology / American Academy of Physical Medicine and
Rehabilitation. Recommended Policy for Electrodiagnostic Medicine. 1994.
2. American Association of Electrodiagnostic Medicine, American Academy of
Neurology, American Academy of Physical Medicine and Rehabilitation. Practice
parameter for electrodiagnostic studies in carpal tunnel syndrome: summary
statement. Muscle Nerve 2002 June;25:918-22.
3. Megerian JT, Kong X, Gozani SN. Utility of Nerve Conduction Studies for Carpal
Tunnel Syndrome by Family Medicine, Primary Care, and Internal Medicine
Physicians. Evidence-Based Clinical Medicine. Journal of the American Board of
Family Medicine. 20 (1): 60-64 (2007). Available at:
http://www.jabfm.org/cgi/content/full/20/1/60
4. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM).
Proper performance and interpretation of electrodiagnostic studies. Muscle
Nerve. 2006;33(3):436-439.
5. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).
Proper performance and interpretation of electrodiagnostic studies. Position
statement. Approved September 2005
6. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).
Recommended policy for electrodiagnostic medicine. Endorsed by the American
Academy of Neurology, The American Academy of Physical Medicine and
Rehabilitation and The American Association of Neuromuscular and
6. Van Asseldonk JT, Franssen H, Van den Berg-Vos RM, et al. Multifocal motor
neuropathy. Lancet Neurol. 2005 May;4(5):309-19.
7. Lee DH, Claussen GC, Oh S. Clinical nerve conduction and needle
electromyography studies. J Am Acad Orthop Surg. 2004 Jul-Aug;12(4):276-87.
8. Barboi AC, Barkhaus PE. Electrodiagnostic testing in neuromuscular disorders.
Neurol Clin. 2004 Aug;22(3):619-41, vi.
9. Chang MH, Wei SJ, Chiang HL, et al. Comparison of motor conduction techniques
in the diagnosis of carpal tunnel syndrome. Neurology. 2002;58(11):1603-1607.
10. Aramideh M, Ongerboer de Visser BW. Brainstem reflexes: Electrodiagnostic
techniques, physiology, normative data, and clinical applications. Muscle Nerve.
2002;26(1):14-30.
11. Wilbourn AJ, Aminoff MJ. AAEE Minimonograph #32: The electrophysiologic
examination in patients with radiculopathies. Muscle Nerve. 1998;21(12):1621-
1631.
12. Braune HJ. Testing of the refractory period in sensory nerve fibers is the most
sensitive method to assess beginning polyneuropathy in diabetics. Electromyogr
Clin Neurophysiol. 1999;39(6):355-359.
13. Esteban A. A neurophysiological approach to brainstem reflexes. Blink reflex.
Neurophysiol Clin. 1999;29(1):7-38.
14. Kaufman MA. Differential diagnosis and pitfalls in electrodiagnostic studies and
special tests for diagnosing compressive neuropathies. Orthop Clin North Am.
1996;27(2):245-252.
15. Hilburn JW. General principles and use of electrodiagnostic studies in carpal and
cubital tunnel syndrome. With special attention to pitfalls and interpretation.
Hand Clin. 1996;12(2):205-221.
16. Agency for Health Care Policy and Research. Laboratory Tests in End-Stage Renal
Disease Patients Undergoing Dialysis. AHCPR Publication No. 94-0053. Health
Technology Assessment Publication No. 2. Rockville, MD: AHCPR, May 1994.
17. Thomas RJ. Blinking and the release reflexes: Are they clinically useful? J Am
Geriatr Soc. 1994;42(6):609-613.
18. No authors listed. Practice parameter for electrodiagnostic studies in carpal
tunnel syndrome. American Academy of Neurology, American Association of
Electrodiagnostic Medicine, and American Academy of Physical Medicine and
Rehabilitation. Neurology. 1993;43(11):2404-2405.
19. Iyer VG. Understanding nerve conduction and electromyographic studies. Hand
Clin. 1993;9(2):273-287.
20. Levin KH. Common focal mononeuropathies and their electrodiagnosis. J Clin
Neurophysiol. 1993;10(2):181-189.
Nerve Conduction Studies Sep 15 28
21. Wertsch JJ, Park TA. Electrodiagnostic medicine. Occup Med. 1992;7(4):765-783.
22. Weber GA. Nerve conduction studies and their clinical applications. Clin Podiatr
Med Surg. 1990;7(1):151-178.
23. Kincaid JC. AAEE Minimonograph #31: The electrodiagnosis of ulnar neuropathy
at the elbow. Muscle Nerve. 1988;11(10):1005-1015.
24. Wilbourn AJ. Electrodiagnosis of plexopathies. Neurol Clin. 1985;3(3):511-529.
Important Notice
General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net’s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member’s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective.
No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member’s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member’s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member’s contract (also known as the
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benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member’s contract shall govern. The Policies do not replace or amend the Member’s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code 1367.63 requires health care service plans to cover reconstructive surgery. “Reconstructive surgery” means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following:
(1) To improve function or
(2) To create a normal appearance, to the extent possible.
Reconstructive surgery does not mean “cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance.
Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery.
Reconstructive Surgery after Mastectomy
California Health and Safety Code 1367.6 requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or
deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation.
