Medical Policy Implementation: Electromyography and Nerve Conduction Studies
Effective February 3, 2016, Horizon Blue Cross Blue Shield of New Jersey will change the way we consider certain claims for electrodiagnostic assessment.
According to the guidelines of our medical policy, Electromyography and Nerve Conduction Studies:
- Electrodiagnostic assessment, consisting of electromyography (EMG), nerve conduction studies (NCS), and related measures, is considered medically necessary as an adjunct to history, physical exam (PE), and imaging studies when the following criteria are met:
- Signs and symptoms of peripheral neuropathy and/or myopathy are present; AND
- Definitive diagnosis cannot be made by PE and imaging studies alone; AND
- Work-up for one or more of the following categories of disease is indicated: compressive neuropathies; nerve root compression; traumatic nerve injuries; generalized and focal polyneuropathies; generalized myopathies; plexopathies; motor neuron diseases; neuromuscular junction disorders; or other, less common disorders for which EMG/NCS provides useful diagnostic information.
- Repeat electrodiagnostic assessment, consisting of Electromyography (EMG), Nerve Conduction Studies (NCS), and related measures, is considered medically necessary when at least one of the following criteria have been met:
- Development of new symptoms or signs suggesting a second diagnosis in a patient who has received an initial diagnosis; OR
- Interim progression of disease following an initial test that was inconclusive, such that a repeat test is likely to elicit additional findings; OR
- Unexpected change(s) in the course of disease or response to treatment, suggesting that the initial diagnosis may be incorrect and that re-examination is indicated.
- Electrodiagnostic assessment, consisting of EMG, NCS and related measures, is considered investigational when the above criteria are not met, including but not limited to, the following situations:
- Screening of asymptomatic individuals
- Serial assessments to evaluate progression of disease in a patients with a previously diagnosed neuropathy or myopathy
- Evaluation of treatment response in a patient with previously diagnosed neuropathy or myopathy
- Evaluation of severity of disease in a patient with previously diagnosed neuropathy or myopathy
Based on the guidelines of our medical policy, Electromyography and Nerve Conduction Studies, AND the submitted diagnosis or diagnoses code(s), CPT®codes 95912 or 95913 submitted on claims for services provided on and after February 3, 2016 may be denied as investigational services.
Review this revised policy in our online Medical Policy Manual.
Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 3, 2016.
CPT® is a registered mark of the American Medical Association.