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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
Nerve Conduction Studies Sep 15 2
None Use Health Net Policy
Instructions
Medicare NCDs and National Coverage Manuals apply to ALL Medicare members
in ALL regions.
Medicare LCDs and Articles apply to members in specific regions. To access your
specific region, select the link provided under “Reference/Website” and follow the
search instructions. Enter the topic and your specific state to find the coverage
determinations for your region. *Note: Health Net must follow local coverage
determinations (LCDs) of Medicare Administration Contractors (MACs) located
outside their service area when those MACs have exclusive coverage of an item
or service. (CMS Manual Chapter 4 Section 90.2)
If more than one source is checked, you need to access all sources as, on
occasion, an LCD or article contains additional coverage information than
contained in the NCD or National Coverage Manual.
If there is no NCD, National Coverage Manual or region specific LCD/Article,
follow the Health Net Hierarchy of Medical Resources for guidance.
Current Policy Statement Health Net, Inc. considers nerve conduction studies medically necessary for any of
the following:
1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome,
ulnar neuropathies or root lesions, for localization.
2. Traumatic nerve lesions, for diagnosis and prognosis.
3. Diagnosis or confirmation of suspected generalized neuropathies, such as
diabetic, uremic, metabolic or immune.
4. Repetitive nerve stimulation in diagnosis of neuromuscular junction
disorders such as myasthenia gravis, myasthenic syndrome.
5. For differential diagnosis of symptom-based complaints (e.g., pain in limb,
weakness, disturbance in skin sensation or paresthesia) provided the clinical
assessment supports the need for a study.
6. Radiculopathy - cervical, lumbosacral.
7. Polyneuropathy - metabolic, degenerative, hereditary.
8. Plexopathy - idiopathic, trauma, infiltration.
9. Myopathy - including polymyositis and dermatomyositis, myotonic, and
congenital myopathies.
10. Precise muscle location for injections such as botulinum toxin, phenol, etc.
Nerve conduction studies have been found to be medically necessary for any of the
following diseases or conditions:
Nerve Conduction Studies Sep 15 3
Alcoholic neuropathy Brachial plexopathy
Carpal tunnel syndrome Charcot-Marie-Tooth disease (hereditary)
Chronic inflammatory polyneuropathy Common peroneal nerve dysfunction
Diabetic neuropathy Diphtheria
Disorders of peripheral nervous system Disturbance of skin sensation
Distal median nerve dysfunction Femoral nerve dysfunction
Fasciculation General paresis
Friedreich's ataxia Joint pain
Guillain-Barre syndrome Mononeuritis multiplex
Lambert-Eaton Syndrome Myopathy
Muscle weakness Nerve effects of uremia
Myositis Neuritis
Nerve root compression Plexopathy
Pain in limb Radial nerve dysfunction
Primary amyloid Secondary systemic amyloid
Sciatic nerve dysfunction Spinal cord injury
Sensorimotor polyneuropathy Tibial nerve dysfunction
Swelling and cramps Ulnar nerve dysfunction
Traumatic injury to a nerve
Note: Nerve conduction velocity studies are essential in evaluating neuromuscular
disorders. They are usually performed in conjunction with needle electromyography.
In limited cases only, nerve conduction velocity studies may be done without needle
electromyography, if the specific criterion noted below is met.
Nerve Conduction Velocity Studies Health Net, Inc. considers the limited use of nerve conduction studies (NCS) or nerve
conduction velocity studies (NCV) done alone as medically necessary, only in any of
the following specific situations:
Established diagnosis of carpal tunnel syndrome; or
Current use of anticoagulants; or
As a follow-up study of neuromuscular structures that have undergone previous
electrodiagnostic evaluation; or
Presence of lymphedema; or
Contraindication to the needle electromyography (NEMG) procedure.
Not Medically Necessary Health Net, Inc. considers any of the following not medically necessary:
Nerve conduction velocity (NCV) studies performed without needle EMG, other
than when performed for the specific indications noted above; or
Automated or hand-held portable noninvasive nerve conduction devices (E.g.,
NC Stat device, Brevio NCS-Monitor) since the diagnostic ability and clinical use
of this type of testing has not been determined.
Nerve Conduction Studies Sep 15 4
Investigational Health Net, Inc. considers surface electromyography (EMG) as a diagnostic tool for
the evaluation of patients with neuromuscular diseases and low back pain
investigational.
Codes Related To This Policy NOTE:
The codes listed in this policy are for reference purposes only. Listing of a code in
this policy does not imply that the service described by this code is a covered or non-
covered health service. Coverage is determined by the benefit documents and
medical necessity criteria. This list of codes may not be all inclusive.
On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and
inpatient procedures will be replaced by ICD-10 code sets. Health Net National
Medical Policies will now include the preliminary ICD-10 codes in preparation for this
transition. Please note that these may not be the final versions of the codes and
that will not be accepted for billing or payment purposes until the October 1, 2015
implementation date.
ICD-9 Codes 005.1 Botulism
037 Tetanus
138 Late effects of acute poliomyelitis
192.0 Malignant neoplasm of cranial nerves
192.2 Malignant neoplasm of spinal cord
192.3 Malignant neoplasm of spinal meninges
192.8 Malignant neoplasm of other specified sites of nervous system
198.3 Secondary malignant neoplasm, brain, and spinal cord
198.4 Secondary malignant neoplasm, other parts of nervous system
225.1 Benign neoplasm of cranial nerve
225.3 Benign neoplasm of spinal cord
225.4 Benign neoplasm of spinal meninges
225.8 Benign neoplasm of other sites of nervous system
237.70-
237.72 Neurofibromatosis
250.61 Diabetes with neurological manifestations; type II [non-insulin
dependent type] [NIDDM type] [adult-onset type] or
unspecified
type, not stated as uncontrolled
250.61 type I [insulin dependent type] [IDDM] [juvenile type], not
stated
as uncontrolled
250.61 type II [non-insulin dependent type] [NIDDM] [adult-onset
type] or
unspecified type, uncontrolled
250.63 type I [insulin dependent type] [IDDM] [juvenile type],
uncontrolled
265.1 Other and unspecified manifestations of thiamine deficiency
269.1 Deficiency of other vitamins
272.5 Lipoprotein deficiencies
333.2 Myoclonus
333.6 Idiopathic torsion dystonia
Nerve Conduction Studies Sep 15 5
333.7 Symptomatic torsion dystonia
333.81 Blepharospasm
333.82 Orofacial dyskinesia
333.83 Spasmodic torticollis
333.84 Organic writer’s cramp
333.89 Fragments of torsions dystonia, other
334.0-
334.9 Spinocerebellar disease
335.0 Werdnig-Hoffmann disease
335.10 Spinal muscular atrophy, unspecified
335.11 Kugelberg-Welander disease
335.19 Other spinal muscular atrophy
335.20-
335.29 Motor neuron disease
335.8 Other anterior horn cell diseases
335.9 Anterior horn cell disease, unspecified
336.0-
336.9 Other diseases of spinal cord
337.0-
337.9 Disorders of the autonomic nervous system (Includes:
disorders of peripheral autonomic, sympathetic,
parasympathetic, or vegetative
system)
340 Multiple sclerosis
341.0 Neuromyelitis optica
341.1 Schilder's disease
341.8 Other demyelinating diseases of central nervous system
341.9 Demyelinating disease of central nervous system, unspecified
342.00-
342.92 Hemiplegia
343.0-
343.9 Infantile cerebral palsy
344.00-
344.5 Monoplegia
344.60 Cauda equina syndrome; without mention of neurogenic
bladder
344.61 with neurogenic bladder
344.81 Other specified paralytic syndromes, locked in state
344.89 Other specified paralytic syndrome
344.9 Paralysis, unspecified
350.1 Trigeminal neuralgia
350.2 Atypical face pain
350.8-
350.9 Other trigeminal nerve disorders
351.0 Bell's palsy
351.1 Geniculate ganglionitis
351.8 Other facial nerve disorders
351.9 Facial nerve disorder, unspecified
352.3 Disorders of pneumogastric (10th) nerve
352.4 Disorders of accessory (11th) nerve
352.5 Disorders of hypoglossal (12th) nerve
352.6 Multiple cranial nerve palsies
352.9 Unspecified disorder of cranial nerves
Nerve Conduction Studies Sep 15 6
353.0 Brachial plexus lesions
353.1 Lumbosacral plexus lesions
353.2 Cervical root lesions, not elsewhere classified
353.3 Thoracic root lesions, not elsewhere classified
353.4 Lumbosacral root lesions, not elsewhere classified
353.5 Neuralgic amyotrophy
353.8 Other nerve root and plexus disorders
353.9 Unspecified nerve root and plexus disorder
354.0-
354.9 Mononeuritis of upper limb and mononeuritis multiplex
355.0-
355.9 Mononeuritis of lower limb and unspecified site
356.0-
356.9 Hereditary and idiopathic peripheral neuropathy
357.0-
357.89 Inflammatory and toxic neuropathy
358.0-
358.9 Myoneural disorders
359.0-
359.9 Myopathy, unspecified
378.00-
378.9 Strabismus and other disorders of binocular eye movements
458.0 Orthostatic hypotension
478.30-
478.34 Paralysis of vocal cords or larynx
478.75 Laryngeal spasm
530.0 Achalasia and cardiospasm
585 Polyneuropathy in uremia
625.6 Stress incontinence, female
646.40-
646.44 Peripheral neuritis in pregnancy
710.3 Dermatomyositis
710.4 Polymyositis
710.5 Eosinophilia myalgia syndrome
721.0 Cervical spondylosis without myelopathy
721.1 Cervical spondylosis with myelopathy
721.2 Thoracic spondylosis without myelopathy
721.3 Lumbosacral spondylosis without myelopathy
721.41 Spondylosis with myelopathy, thoracic region
721.42 Spondylosis with myelopathy, lumbar region
721.5-
721.91 Other spondylopathies
Displacement of cervical, thoracic, or lumbar intervertebral disc
without myelopathy
722.0 Displacement of intervertebral disc, site unspecified, without
722.11 myelopathy
722.30-
722.39 Schmorl’s nodes
722.4 Degeneration of cervical intervertebral disc
722.51 Degeneration of thoracic or thoracolumbar intervertebral disc
722.52 Degeneration of lumbar or lumbosacral intervertebral disc
722.6 Degeneration of intervertebral disc, site unspecified
722.70-
Nerve Conduction Studies Sep 15 7
722.73 Invertebral disc disorder with myelopathy
722.80-
722.83 Postlaminectomy syndrome
722.90 Other and unspecified disc disorder, unspecified region
722.91-
722.93 Other specified disc disorder
723.0 Spinal stenosis in cervical region
723.1 Cervicalgia
723.4 Brachial neuritis or radiculitis NOS
723.5 Torticollis, unspecified
724.00-
724.09 Spinal stenosis, other than cervical
724.1 Pain in thoracic spine
724.2 Lumbago
724.3 Sciatica
724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5 Backache, unspecified
724.9 Compression of spinal nerve root
725 Polymyalgia rheumatica
728.0 Infective myositis
728.2 Muscular wasting and disuse atrophy, not elsewhere classified
728.85 Spasm of muscle
729.1 Myalgia and myositis, unspecified
729.2 Neuralgia, neuritis, and radiculitis, unspecified
729.5 Pain in limb
729.82 Other musculoskeletal symptoms referable to limbs, cramps
736.05 Wrist drop (acquired)
736.06 Claw hand (acquired)
736.09 Other acquired deformities of forearm, excluding fingers
736.70-
736.76 Acquired deformities of ankle and foot
736.79 Other acquired deformities of ankle and foot
741.90-
741.93 Spina bifida without mention of hydrocephalus
742.51 Diastematomyelia
780.79 Other malaise and fatigue
781.0 Abnormal involuntary movements
781.2-
781.3 Abnormality of gait, lack of coordination
781.4 Transient paralysis of limb
781.7 Tetany
782.0 Disturbance of skin sensation
784.49 Other disturbance, including spasmodic dysphonia
787.6 Incontinence of feces
788.21 Incomplete bladder emptying
788.30-
788.39 Incontinence of urine
794.17 Abnormal electromyogram
806.00-
806.9 Fracture of vertebral column with spinal cord injury
951.4 Injury to facial nerve
951.8 Injury to other specified cranial nerve
952.00-
Nerve Conduction Studies Sep 15 8
952.09 Spinal cord injury without evidence of spinal bone injury,
cervical
952.10 Spinal cord injury without evidence of spinal bone injury, dorsal
952.19 thoracic
952.2 Lumbar spinal cord injury without spinal bone injury
952.3 Sacral spinal cord injury without spinal bone injury
952.4 Cauda equina spinal cord injury without spinal bone injury
952.8 Multiple sites of spinal cord injury without spinal bone injury
952.9 Unspecified site of spinal cord injury without spinal bone injury
953.0-
953.9 Injury to nerve roots and spinal plexus
954.0 Injury to other nerve(s) of trunk, excluding shoulder and pelvic
girdles
954.9
955.0-
955.9 Injury to peripheral nerve(s) of shoulder girdle and upper limb
956.0-
956.9 Injury to peripheral nerve(s) of pelvic girdle and lower limb
957.0-
957.9 Injury to other and unspecified nerves
994.8 Electrocution and nonfatal effects of electric current
ICD-10 Codes A05.1 Botulism food poisoning
A35 Other tetanus
B91 Sequelae of poliomyelitis
C72.0-
C72.9 Malignant neoplasm of spinal cord, cranial nerves and other
parts of central nervous system
C79.31 Secondary malignant neoplasm of brain
C79.32 Secondary malignant neoplasm of cerebral meninges
C79.49 Secondary malignant neoplasm of other parts of nervous
system
D32.0-
D32.9 Benign neoplasm of meninges
D33.3 Benign neoplasm of cranial nerves
D33.4 Benign neoplasm of spinal cord
D33.7 Benign neoplasm of other specified parts of central nervous
system
E10.40-E10.49 Type 1 diabetes mellitus with neurological complications
E11.40-E11.49 Type 2 diabetes mellitus with neurological complications
E51.8 Other manifestations of thiamine deficiency
E51.9 Thiamine deficiency, unspecified
E56.0-E56.9 Other vitamin deficiencies
E78.6 Lipoprotein deficiency
G11.0-G11.9 Hereditary ataxia
G12.0 Infantile spinal muscular atrophy, type I [Werdnig-Hoffman]
G12.1 Other inherited spinal muscular atrophy
G12.20-G12.29 Motor neuron disease
G12.8 Other spinal muscular atrophies and related syndromes
G12.9 Spinal muscular atrophy, unspecified
G14 Postpolio syndrome
G24.1 Genetic torsion dystonia
Nerve Conduction Studies Sep 15 9
G24.3 Spasmodic torticollis
G24.4 Idiopathic orofacial dystonia
G24.5 Blepharospasm
G24.9 Dystonia, unspecified
G25.3 Myoclonus
G25.89 Other specified extrapyramidal and movement disorders
G35 Multiple sclerosis
G36.0 Neuromyelitis optica [Devic]
G37.0 Diffuse sclerosis of central nervous system
G37.5 Concentric sclerosis [Balo] of central nervous system
G37.9 Demyelinating disease of central nervous system, unspecified
G50.0-G50.9 Disorders of trigeminal nerve
G51.0-G51.9 Facial nerve disorders
G52.2 Disorders of vagus nerve
G52.3 Disorders of hypoglossal nerve
G52.7 Disorders of multiple cranial nerves
G52.8 Disorders of other specified cranial nerves
G52.9 Cranial nerve disorder, unspecified
G54.0-G54.9 Nerve root and plexus disorders
G56.00-G56.92 Mononeuropathies of upper limb
G57.00-G57.92 Mononeuropathies of lower limb
G60.0-G65.2 Polyneuropathies and other disorders of the peripheral nervous
system
G70.00-G73.9 Diseases of myoneural junction and muscle
G80.0-G80.9 Cerebral palsy
G81.00-G81.94 Hemiplegia and hemiparesis
G83.0-G83.9 Other paralytic syndromes
G90.01-G90.9 Disorders of autonomic nervous system
G95.0-G95.9 Other and unspecified diseases of spinal cord
H50.00-H50.9 Other strabismus
H51.0-H51.9 Other disorders of binocular movement
I95.1 Orthostatic hypotension
J38.00-J38.02 Paralysis of vocal cords and larynx
J38.5 Laryngeal spasm
K22.0 Achalasia of cardia
M21.33- M21.379 Wrist or foot drop (aquired)
M21.511- M21.519 Acquired clawhand
M21.6X1- M21.6X9 Other acquired deformities of foot
M21.83- M21.839 Other specified acquired deformities of unspecified forearm
M21.961- M21.969 Unspecified acquired deformity of lower leg
M33.00-M33.99 Dermatopolymyositis
M35.3 Polymyalgia rheumatica
M35.8 Other specified systemic involvement of connective tissue
M47.01-M47.9 Spondylosis
M50.00-M50.93 Cervical Disc disorders
M51.04-M51.9 Thoracic, thoracolumbar, and lumbosacral intervertebral disc
disorders
M53.0-M53.9 Other and unspecified dorsopathies, not elsewhere classified
M54.10 Radiculopathy, site unspecified
M60.009 Infective myositis, unspecified site
M60.9 Myositis, unspecified
M62.40 Contracture of muscle, unspecified site
Nerve Conduction Studies Sep 15 10
M62.50 Muscle wasting and atrophy, not elsewhere classified,
unspecified site
M62.838 Other muscle spasm
M79.1 Myalgia
M79.2 Neuralgia and neuritis, unspecified
M79.609 Pain in unspecified limb
M79.7 Fibromyalgia
N18.9 Chronic Kidney disease, unspecified
N39.3 Stress incontinence (female) (male)
N39.41 Urge incontinence
N39.42 Incontinence without sensory awareness
N39.43 Post-void dribbling
N39.44 Nocturnal enuresis
N39.45 Continuous leakage
N39.46 Mixed incontinence
N39.490 Overflow incontinence
N39.498 Other specified urinary incontinence
Q05.5 Cervical spina bifida without hydrocephalus
Q05.6 Thoracic spina bifida without hydrocephalus
QØ5.7 Lumbar spina bifida without hydrocephalus
Q05.8 Sacral spina bifida without hydrocephalus
Q06.2 Diastematomyelia
O26.821- O26.829 Pregnancy related peripheral neuritis
Q85.00 Neurofibromatosis, unspecified
Q85.01 Neurofibromatosis, type 1
Q85.02 Neurofibromatosis, type 2
R15.0-R51.9 Fecal incontinence
R20.0-R20.9 Disturbance of skin sensation
R25.0-R25.9 Abnormal involuntary movements
R26.0-R26.9 Abnormalities of gait and mobility
R27.0-R27.9 Other lack of coordination
R29.0 Tetany
R29.5 Transient paralysis
R32 Unspecified urinary incontinence
R39.14 Feeling of incomplete bladder emptying
R49.8 Other voice and resonance disorders
R53.81-R53.83 Other malaise and fatigue
R94.131 Abnormal electromyogram [EMG]
S04.5-S04.52 Injury of facial nerve
S04.811-S04.9 Injury of other cranial nerves
S12.000-S12.9 Fracture of cervical vertebra and othe parts of the neck
S13.0-S13.9 Dislocation and sprain of joints and ligaments at neck level
S14.101-S14.9 Injury of nerves and spinal cord at neck level
S22.000- S22.089 Fracture of thoracic vertebra
S24.0-S24.9 Injury of nerves and spinal cord at thorax level
S32.000-S32.059 Fracture of lumbar vertebra
S32.10-S32.19 Fracture of sacrum
S32.2 Fracture of coccyx
S34.01-S34.9 Injury of lumbar and sacral spinal cord and nerves at abdomen,
lower back and pelvis level
S44.00-S44.92 Injury of nerves at shoulder and upper arm level
S74.00-S74.92 Injury of nerves at hip and thigh level
S84.00-S84.92 Injury of nerves at lower leg level
Nerve Conduction Studies Sep 15 11
S94.00-S94.92 Injury of nerves at ankle and foot level
T75.4 Electrocution
CPT Codes 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; larnyx
95866 Needle electromyography; hemidiaphragm
95867 Needle electromyography; cranial nerve supplied muscle(s),
unilateral
95868 Needle electromyography; cranial nerve supplied muscle(s),
bilateral
95869 Needle electromyography; thoracic paraspinal muscles
(excluding T1 or T12)
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 95900 Nerve conduction, amplitude and latency/velocity study, each
nerve; motor, without f-wave study (code deleted 12/2012)
95903 Nerve conduction, amplitude and latency/velocity study, each
nerve; motor, with f-wave study (code deleted 12/2012)
95904 Nerve conduction, amplitude and latency/velocity study, each
nerve; sensory (code deleted 12/2012)
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; 11-12 studies
95913 Nerve conduction studies; 13 or more studies
95933 Orbicularis oculi (blink) reflex, by electrodiagnostic testing
95934 H-reflex, amplitude and latency study; record
gastrocnemius/soleus muscle (code deleted 12/2012)
95936 H-reflex, amplitude and latency study; record muscle other
than gastrocnemius/soleus muscle (code deleted 12/2012)
95937 Neuromuscular junction testing (repetitive stimulation, paired
stimuli), each nerve, any one method
95999 Unlisted neurological or neuromuscular diagnostic procedure
96002 Dynamic surface electromyography, during walking or other
functional activities, 1-12 muscles
HCPCS Codes N/A
Nerve Conduction Studies Sep 15 12
Scientific Rationale – Update September 2013 The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
recommends that nerve conduction studies and electromyography should be
performed and interpreted at the same time in the majority of situations. This is
critically important in patients with suspected radiculopathy, plexopathy, myopathy,
motor neuropathy, or motor neuron disease. In addition, the complementary
information derived from electromyography is useful to ensure that an underlying
disease process is not missed (eg, radiculopathy in a patient with suspected carpal
tunnel syndrome).
Scientific Rationale – Update September 2012 There are two main types of electromyography (EMG), needle EMG (NEMG) and
surface EMG (SEMG). NEMG, in combination with nerve conduction studies, is
considered the gold standard methodology for assessing the neurophysiologic
characteristics of neuromuscular diseases. SEMG is being investigated as a
noninvasive alternative modality to NEMG. SEMG, also referred to as scanning EMG
or surface scanning EMG, is a technique to measure muscle activity noninvasively
using surface electrodes placed on the skin overlying the muscle. Unlike NEMG,
SEMG electrodes record from a wide area of muscle territory, have a relatively
narrow frequency band, have low-signal resolution, and are highly susceptible to
movement artifact. SEMG can be conducted with the patient standing or lying down
or performing an isometric hold, contraction, or exertion (static SEMG); performing a
movement such as flexion and reextension (dynamic SEMG); responding to an
increase or decrease of a physical challenge or undergoing combined static and
dynamic investigations.
A report on the clinical utility of surface EMG from the American Academy of
Neurology (2000) concluded:
Based on Class II data, SEMG is considered unacceptable as a clinical tool in the
diagnosis of neuromuscular disease.
Based on Class III and inconclusive or inadequate Class II data, SEMG is
considered unacceptable as a clinical tool in the evaluation of patients with low
back pain.
Based on Class III data, SEMG is considered an acceptable tool for kinesiologic
analysis of movement disorders; for differentiating types of tremors, myoclonus,
and dystonia; for evaluating gait and posture disturbances; and for evaluating
psychophysical measures of reaction and movement time.
The AAN recommends further studies comparing specificity and sensitivity of fine
wire EMG with SEMG are to be encouraged.
Peer review literature is very limited. Enomoto et al (2012) measured paravertebral
muscle activity SEMG in lumbar degenerative patients and healthy volunteers.
Muscle activity was tested in the standing position, and the influence of low back
pain and alignment of the lumbar spine was assessed in the patients with lumbar
kyphosis or canal stenosis. The subjects were kyphosis patients who were 60 years
of age or older, age-matched lumbar spinal canal stenosis patients and healthy
volunteers. Muscular activity at the L1-2 and L4-5 intervertebral areas was recorded
by surface EMG in the resting standing position and also with a weight load held in
Nerve Conduction Studies Sep 15 13
the standing position. Muscle activity and muscle fatigue, as well as the association
between the visual analogue scale, Japanese Orthopaedic Association score for low
back pain and muscle activity, were analyzed. Kyphosis patients had greater muscle
activity in the lower back in the resting standing position and more severe muscle
fatigue at the upper lumbar spine in comparison to patients with lumbar spinal canal
stenosis. There was no association between muscle activity and clinical findings in
patients with lumbar kyphosis although. Investigators concluded the study revealed
the constant activity of paravertebral muscles and the susceptibility to muscle fatigue
in patients with lumbar kyphosis. The quantification of muscle activity by surface
EMG may show the pathology of lumbar kyphosis, and the decrease of muscle
activity in the standing position may be a potentially useful index for guiding
treatment.
Uesugi et al (2011) sought to establish a non-invasive and quantitative analysis
method using single-channel surface EMG (SEMG) for diagnosing neurogenic and
myopathic changes. The subjects consisted of 66 healthy controls, 12 patients with
neurogenic diseases, and 18 patients with myopathic diseases. The tibialis anterior
muscle was examined using a belly to the adjacent bone lead. From each subject,
20-40 signals of 1 s length were collected of various strengths. A new parameter, the
"Clustering Index (CI)", was developed to quantify the uneven distribution of the
SEMG signal, and was plotted against the SEMG area. The results were expressed as
the Z-score of each subject calculated using linear regression from the normative
data. When ±2.5 was used as the cut-off value of the Z-score, the specificity was
95%, whereas the sensitivity was 92% (11/12) and 61% (11/18) for the neurogenic
and myopathic patients, respectively. There was no overlap of the Z-score values
between the neurogenic and myopathic groups. Investigators concluded the CI
method achieved a reasonably high diagnostic yield in detecting neurogenic or
myopathic changes.
Liu et al (2011) proposed modeling the activity coordination network between lumbar
muscles using SEMG signals and performing the network analysis to compare the
lumbar muscle coordination patterns between patients with low back pain (LBP) and
healthy control subjects. Ten healthy subjects and eleven LBP patients were asked to
perform flexion-extension task, and the SEMG signals were recorded. Both the
subject-level and the group-level PC(fdr) algorithms are applied to learn the SEMG
coordination networks with the error-rate being controlled. The network features are
further characterized in terms of network symmetry, global efficiency, clustering
coefficient and graph modules. The results indicate that the networks representing
the normal group are much closer to the order networks and clearly exhibit globally
symmetric patterns between the left and right SEMG channels. While the
coordination activities between SEMG channels for the patient group are more likely
to cluster locally and the group network shows the loss of global symmetric patterns.
They concluded as a complementary tool to the physical and anatomical analysis, the
proposed network analysis approach allows the visualization of the muscle
coordination activities and the extraction of more informative features from the sEMG
data for low back pain studies.
Scientific Rationale – Update December 2011 Schmidt et al. (2011) completed a study in which the authors compared the
specificity and sensitivity of a hand-held NCS device for the detection of lumbosacral
Nerve Conduction Studies Sep 15 14
radiculopathy with standard electrodiagnostic study (EDX). Fifty patients referred to
a tertiary referral electromyography (EMG) laboratory for testing of predominantly
unilateral leg symptoms (weakness, sensory complaints, and/or pain) were included
in the investigation. Twenty-five normal "control" subjects were later recruited to
calculate the specificity of the automated protocol. All patients underwent standard
EDX and automated testing. Raw NCS data were comparable for both techniques;
however, computer-generated interpretations delivered by the automated device
showed high sensitivity with low specificity (i.e., many false positives) in both
symptomatic patients and normal controls. The automated device accurately
recorded raw data, but the interpretations provided were overly sensitive and lacked
the specificity necessary for a screening or diagnostic examination.
The official medical journal of the American Association of Neuromuscular and
Electrodiagnostic Medicine (AANEM) Muscle & Nerve, compared the specificity and
sensitivity of the handheld NCS device for the detection of lumbosacral radiculopathy
(LSR) with a standard electrodiagnostic study. The results showed the raw NCS data
was comparable for both techniques; however, computer-generated interpretations
delivered by the automated device showed high sensitivity with low specificity (i.e.,
many false positives) in both symptomatic patients and normal controls. The study
noted above by Dr. Schmidt, results suggest the hand-held NCS device tested
significantly over-diagnoses LSR in both symptomatic and asymptomatic subjects,
which may lead to unnecessary intervention or repeated testing. The findings of the
study do not support the clinical application of automated testing in the diagnosis of LSR.
Scientific Rationale – Update March 2011 Because nerve conduction studies performed with devices that use fixed anatomic
templates and computer-generated reports (such as the NC-Stat device), are a local
Medicare covered service in specific situations only, as dictated by certain local
Medicare carriers, it must be covered for all Medicare Advantage members who
reside in the local area in which coverage is applicable, subject to the relevant
Medicare criteria and/or guidelines. Medicare does not expect this testing to be used
routinely on all patients. For Local Medicare coverage determination, please go to the individual local Medicare website.
Nerve Conduction Studies (NCS) (including Nerve Conduction Velocity Studies (NCV)
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
Electrodiagnostic Medicine. Updated 2004.
Nerve Conduction Studies Sep 15 24
7. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).
Model policy for needle electromyography and nerve conduction velocity studies.
June 2010. Updated December 2012.
8. Pullman SL, Goodin DL, Marquinez AI et al. Clinical utility of surface EMG.
Report of the Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology. Neurology 2000;55:171–177.
9. Hayes Medical Technology Directory. Surface Electromyography for Evaluation
of Low Back Pain. Dec 2005. Archived Jan 2011
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10.1016/j.diabres.2015.07.009. [Epub ahead of print]
2. Weinberg DH. Electrodiagnostic testing of the neuromuscular junction.
UpToDate. April 2015.
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2013; 5:S3.
2. Karami-Mohajeri S, Nikfar S, Abdollahi M. A systematic review on the nerve-
muscle electrophysiology in human organophosphorus pesticide exposure. Hum
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3. Nandedkar SD, Sheridan C, Bertoni S, et al. Deep brain stimulator artifact in
needle electromyography: effects and distribution in paraspinal and upper limb
muscle. Muscle Nerve 2013; 47:561.
4. Preston DC, Shapiro BE. Electrical safety and iatrogenic complications. In:
Electromyography and Neuromuscular Disorders: Clinical–Electrophysiologic
Correlations, Third edition, Elsevier, New York 2013. p.614.
References – Update September 2013 1. Becker SJ, Makanji HS, Ring D. Changes in treatment plan for carpal tunnel
syndrome based on electrodiagnostic test results. J Hand Surg Eur Vol. 2013
Aug 1
2. Gasca-Salas C, Arcocha J, Artieda J, Pastor P. Orthostatic myoclonus: An
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2.
3. Hakimi K, Spanier D. Electrodiagnosis of cervical radiculopathy. Phys Med
Rehabil Clin N Am. 2013 Feb;24(1):1-12
4. Inal EE, Eser F, Aktekin LA, Oksüz E, Bodur H. Comparison of clinical and
electrophysiological findings in patients with suspected radiculopathies. J Back
Musculoskelet Rehabil. 2013 Jan 1;26(2):169-73.
5. Jiang CF, Lin YC, Yu NY. Multi-scale surface electromyography modeling to
identify changes in neuromuscular activation with myofascial pain. IEEE Trans
Neural Syst Rehabil Eng. 2013 Jan;21(1):88-95.
6. Kumar DK, Poosapadi Arjunan S, Singh VP. Towards identification of finger
flexions using single channel surface electromyography--able bodied and
amputee subjects. J Neuroeng Rehabil. 2013 Jun 7;10:50.
7. Nandedkar SD. Emerging techniques in the electrodiagnostic laboratory. PM R.
2013 May;5(5 Suppl):S115-22.
8. Sivadasan A, Sanjay M, Alexander M, et al. Utility of multi-channel surface
electromyography in assessment of focal hand dystonia. Muscle Nerve. 2012
Dec 18. doi: 10.1002/mus.23762.
Nerve Conduction Studies Sep 15 25
References – Update September 2012 1. Enomoto M, Ukegawa D, Sakaki K, et al. Increase of Paravertebral Muscle
Activity in Lumbar Kyphosis Patients by Surface Electromyography Compared
With Lumbar Spinal Canal Stenosis Patients and Healthy Volunteers. J Spinal
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2. Liu A, Wang ZJ, Hu Y. Network modeling and analysis of lumbar muscle surface
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3. Uesugi H, Sonoo M, Stålberg E, et al. “Clustering Index method": a new
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References – Update December 2011 1. England JD, Franklin GM. Automated hand-held nerve conduction devices: raw
data, raw interpretations. Muscle Nerve. 2011 Jan;43(1):6-8. doi:
10.1002/mus.21960.
2. Kong X, Lesser EA, Gozani SN. Repeatability of nerve conduction measurements
derived entirely by computer methods. Biomed Eng Online. 2009;8:33.
3. Schmidt K, Chinea NM, Sorenson EJ, et al. Accuracy of diagnoses delivered by an
automated hand-held nerve conduction device in comparison to standard
electrophysiological testing in patients with unilateral leg symptoms. Muscle
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References – Update March 2011 1. Baum P, Bercker S, Villmann T, et al. Nervenarzt. Critical illness myopathy and
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2. Gazioglu S, Boz C, Cakmak VA. Electrodiagnosis of carpal tunnel syndrome in
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ahead of print]
3. Friedrich JM, Robinson LR. Prognostic indicators from electrodiagnostic studies
for ulnar neuropathy at the elbow. Muscle Nerve. 2011 Feb 11. doi:
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4. Horowitz SH. Overview of nerve conduction studies. UpToDate. February 4,
2010. Updated February 17, 2014.
5. Asad A. Comparison of nerve conduction studies with diabetic neuropathy
symptom score and diabetic neuropathy examination score in type-2 diabetics
for detection of sensorimotor polyneuropathy. J Pak Med Assoc. 01-SEP-2009;
59(9): 594-8
References – Update February 2009 1. Centers for Medicare and Medicaid Services, (CMS). LCD for Nervous System
STUDIES - Autonomic Function, NERVE CONDUCTION and ELECTROMYOGRAPHY
(L28282). Palmetta GBA (01102 - MAC - Part B) (Northern California). Updated
1/15/2009.
2. Centers for Medicare and Medicaid Services, (CMS). LCD for Nervous System
STUDIES - Autonomic Function, NERVE CONDUCTION and ELECTROMYOGRAPHY
(L28282) Palmetta GBA (01192 - MAC - Part B) (Southern California). Updated
1/15/2009.
3. Neal PJ, Katirji B. Performance standards of the nerve conduction study
technologist. Am J Electroneurodiagnostic Technol. 2008 Jun; 48 (2): 72-8.
Nerve Conduction Studies Sep 15 26
4. Lesser EA, Starr J, Kong X, Megerian JT, et al. Point-of-service nerve conduction
studies: an example of industry-driven disruptive innovation in health care.
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5. Jabre JF, Salzsieder BT, Gnemi KE. Criterion validity of the NC-stat automated
nerve conduction measurement instrument. Neurology Service, Boston VA
Healthcare System. Physiol Meas. 2007 Jan;28(1):95-104. Epub 2006 Nov 30.
6. Washington State Department of Labor and Industries. Coverage Decision: NC-
Stat conduction Testing System. 06-01 February 2006; 2P. Available at:
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7. Kong X, Gozani SN, Hayes MT, Weinberg DH. NC-stat sensory nerve conduction
studies in the median and ulnar nerves of symptomatic patients. Clin
Neurophysiol. 2006;117(2):405-413.
8. Elkowitz SJ, Dubin NH, Richards BE, Wilgis EF. Clinical utility of portable versus
traditional electrodiagnostic testing for diagnosing, evaluating, and treating
carpal tunnel syndrome. Am J Orthop. 2005;34(8):362-364.
9. Vinik AI, Emley MS, Megerian JT, Gozani SN. Median and ulnar nerve conduction
measurements in patients with symptoms of diabetic peripheral neuropathy
using the NC-stat system. Diabetes Technol Ther. 2004;6(6):816-824.
10. Leffler CT, Gozani SN, Cros D. Median neuropathy at the wrist: diagnostic utility
of clinical findings and an automated electrodiagnostic device. J Occup Environ
Med. 2000;42(4):398-409.
References – Update November 2008 1. Hayes Medical Technology Brief. Nc-stat System (NeuroMetrix Inc.) for
Noninvasive Nerve Conduction Testing of Upper Extremity Neuropathy.
November 2007.
2. Morse J. NC-stat System, NeuroMetrix Inc. (Nerve Conduction Testing System).
Technology Assessment. Olympia, WA: Office of the Medical Director,
Washington State Department of Labor and Industries; June 8, 2006.
3. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM).
Proper performance and interpretation of electrodiagnostic studies. Muscle
Nerve. 2006; 33 (3): 436-439.
References – Update June 2007 1. Jabre JF, Salzsieder BT, Gnemi KE. Criterion validity of the NC-stat automated
nerve conduction measurement instrument. Physiol Meas. 2007; 28(1):95-104
2. Morse, J. Office of the Medical Director, Department of Labor and Industries.
Washington State Department of Labor and Industries. Technology Assessment:
NC-stat System, NeuroMetrix, Inc. June 8, 2006. Available at:
http://www.lni.wa.gov/ClaimsIns/Files/OMD/taNCSTAT0506.pdf
3. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).
Proper performance and interpretation of electrodiagnostic studies. Position
statement. Approved September 2005. Muscle Nerve. 2006; 33:436-439.
4. Avitzur O. Neurologists respond as new neurodiagnostic test invades the general
market. Neurology Today. 2006;6(14):4-5. American Academy of Neurology.
5. Kong X, Lesser EA, Megerian JT, et al. Repeatability of nerve conduction
measurements using automation. J Clin Monit Comput. 2006;20(6):405-410
6. Kong X, Gozani SN, Hayes MT, et al. NC-stat sensory nerve conduction studies in
the median and ulnar nerves of symptomatic patients. Clin Neurophysiol.
2006;117(2):405-413
Nerve Conduction Studies Sep 15 27
7. Elkowitz SJ, Dubin NH, Richards BE, et al. Clinical utility of portable versus
traditional electrodiagnostic testing for diagnosing, evaluating and treating
carpal tunnel syndrome. Am J Orthop. 2005; 34(8):362-364
References - Initial
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2. Rider DA. Functional tests to quantify recovery following carpal tunnel release.
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3. Mallik A, Weir AI. Nerve conduction studies: essentials and pitfalls in practice.
J Neurol Neurosurg Psychiatry. 2005 Jun;76 Suppl 2:ii23-31.
4. Perry JD. Electrodiagnosis in musculo-skeletal disease. Best Pract Res Clin
Rheumatol. 2005 Jun;19(3):453-66.
5. Fuller G. How to get the most out of nerve conduction studies and
electromyography. J Neurol Neurosurg Psychiatry. 2005 Jun;76 Suppl 2:ii41-46.
6. Van Asseldonk JT, Franssen H, Van den Berg-Vos RM, et al. Multifocal motor
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7. Lee DH, Claussen GC, Oh S. Clinical nerve conduction and needle
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10. Aramideh M, Ongerboer de Visser BW. Brainstem reflexes: Electrodiagnostic
techniques, physiology, normative data, and clinical applications. Muscle Nerve.
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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
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13. Esteban A. A neurophysiological approach to brainstem reflexes. Blink reflex.
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21. Wertsch JJ, Park TA. Electrodiagnostic medicine. Occup Med. 1992;7(4):765-783.
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