Electromyography and Nerve Conduction Studies

Transcription

MEDICAL POLICY
POLICY TITLE
ELECTROMYOGRAPHY and NERVE CONDUCTION STUDIES
POLICY NUMBER
MP-2.063
Original Issue Date (Created):
10/4/2002
Most Recent Review Date (Revised):
1/26/2016
Effective Date:
8/5/2016
POLICY
RATIONALE
DISCLAIMER
POLICY HISTORY
PRODUCT VARIATIONS
DEFINITIONS
CODING INFORMATION
DESCRIPTION/BACKGROUND
BENEFIT VARIATIONS
REFERENCES
I. POLICY
Electrodiagnostic assessment, consisting of EMG, NCS, and related measures, may be
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 1 or more of the following categories of disease is indicated (see Policy
Guidelines section):
o Compressive neuropathies
o Nerve root compression
o Traumatic nerve injuries
o Generalized and focal neuropathies/myopathies
o Plexopathies
o Motor neuron diseases
o Neuromuscular junction disorders
A repeat electrodiagnostic assessment may be considered medically necessary when at least
1 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 reexamination is indicated.
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Electrodiagnostic assessment, consisting of EMG, NCS, and related measures, is
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
There is insufficient evidence to support a conclusion concerning the health outcomes or
benefits associated with testing for these indications.
Policy Guidelines
The following list gives specific diagnoses, according to categories of testing listed in the
policy statement, for which EMG/NCS generally provides useful information in confirming or
excluding the diagnosis, above that provided by clinical examination and imaging. It includes
the most common diagnoses for testing, but it is not exhaustive. There may also be other less
common disorders for which EMG/NCS provides useful diagnostic information.
 Compressive neuropathies
o Carpal tunnel syndrome
o Ulnar nerve entrapment
o Thoracic outlet syndrome
o Tarsal tunnel syndrome
o Other peripheral nerve entrapments
 Nerve root compression (when PE and magnetic resonance imaging [MRI] are
inconclusive)
o Cervical nerve root compression
o Thoracic nerve root compression
o Lumbosacral nerve root compression
 Traumatic nerve injuries
 Generalized and focal polyneuropathies
o Diabetic neuropathy
o Uremic neuropathy
o Alcohol-related neuropathy
o Hereditary neuropathies
 Charcot-Marie Tooth
 Other hereditary neuropathies
o Demyelinating polyneuropathies
 Guillain-Barré syndrome (acute)
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
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 Chronic idiopathic demyelinating polyneuropathy
Generalized myopathies
o Polymyositis
o Dermatomyositis
Plexopathies
o Cervical plexopathy
o Brachial plexopathy
o Lumbosacral plexopathy
Motor neuron diseases
o Amyotrophic lateral sclerosis
o Progressive muscular atrophy
o Progressive bulbar palsy
o Pseudobulbar palsy
o Primary lateral sclerosis
Neuromuscular junction disorders
o Myasthenia gravis
o Myasthenic syndrome
o Lambert-Eaton syndrome
The following recommendations on the number of repeat services are reproduced from the
AANEM Position Statement.1 These numbers do not represent absolute maximums for all
patients; they are defined by AANEM as being sufficient to make a diagnosis in at least 90%
of patients with that particular diagnosis. Therefore, there may be a small percentage of
cases that require a greater number of tests than specified in this table.
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The AANEM position statement also included minimum standards for a lab performing
electrodiagnostic evaluation.1 These are:

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The tests should be medically indicated.
The tests should be performed using equipment that provides assessment of all parameters
of the recorded signals. Equipment designed for screening purposes is not acceptable.
The NCS should be performed by a physician or by a trained technician under the direct
supervision of a physician.
A trained physician must perform the needle EMG exam.
One physician should perform and supervise all components of the electrodiagnostic
testing.
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Cross-reference:
MP-2.096 Electromyography (EMG) (Needle and Non-Needle) of the Urethral Sphincter
MP-2.097 Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain
MP-2.099 Automated Point-of-Care Nerve Conduction Tests
MP-2.098 Quantitative Sensory Testing
II. PRODUCT VARIATIONS
Top
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids
[N] PPO
[N] HMO
[Y] Senior Blue HMO*
[Y] Senior Blue PPO*
[N] Indemnity
[N] Special Care
[N] POS
[N] FEP PPO
* Refer to the following Novitas Local Coverage Determinations (LCD)
•
•
L35081 Nerve Conduction Studies and Electromyography
L34996 Neuromuscular Junction Testing
III. DESCRIPTION/BACKGROUND
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Electromyography and Nerve Conduction Studies
EMG and NCS have been used for several decades as adjuncts to the clinical examination in the
evaluation of myopathy and peripheral neuropathy.2 The intent of these tests is to evaluate the
integrity and electrical function of muscles and peripheral nerves. They are performed when
there is a clinical suspicion for a myopathic or neuropathic process and when clinical
examination and standard laboratory testing is unable to make a definitive diagnosis.
The results of these tests do not generally provide a specific diagnosis. Rather, they provide
additional information that assists the physician in characterizing a clinical syndrome.
According to the American Association of Neuromuscular and Electrodiagnostic Medicine,
electrodiagnostic assessment has the following goals1:

Identify normal and abnormal nerve, muscle, motor or sensory neuron, and
neuromuscular junction (NMJ) functioning

Localize region(s) of abnormal function

Define the type of abnormal function

Determine the distribution of abnormalities

Determine the severity of abnormalities

Estimate the date of a specific nerve injury

Estimate the duration of the disease

Determine the progression of abnormalities or of recovery from abnormal function

Aid in diagnosis and prognosis of disease
 Aid in selecting treatment options
 Aid in following response to treatment by providing objective evidence of change
in NM function
 Localize correct locations for injections of intramuscular agents
Components of the electrodiagnostic exam may include the following:
 Needle EMG. A needle electrode in inserted into selected muscles, chosen by the
examining physician depending on the differential diagnosis and other information
available at the time of exam.1 The response of the muscle to electrical stimulation is
recorded. There are 3 components evaluated: observation at rest, action potential with
minimal voluntary contraction, and action potential with maximum contraction.3
o Single fiber EMG. In this technique, a needle electrode records the response of a
single muscle fiber. This test can evaluate “jitter”, which is defined as the variability
in time between activation of the nerve and generation of the muscle action
potential. Single fiber EMG can also be used to measure fiber density, which is
defined as the mean number of muscle fibers for 1 motor unit.
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
NCS. Both motor and sensory nerve conduction are assessed. For motor conduction,
electrical stimuli are delivered along various points on the nerve and the electrical
response is recorded from the appropriate muscle. For sensory conduction, electrical
stimuli are delivered to 1 point on the nerve and the response recorded at a distal point
on the nerve. Parameters recorded include velocity, amplitude, latency, and
configuration.2
o Late wave responses. Late waves are a complement to the basic NCS study and
evaluate the functioning of the proximal segment of peripheral nerves, such as the
nerve root and the anterior horn cells. There are 2 types of late responses, the Hreflex and the F wave.
 H-reflex. The H reflex is elicited by stimulating the posterior tibial nerve and
measuring the response in the gastrocnemius muscle. It is analogous to the
ankle reflex and can be prolonged by a radiculopathy at S1 or by a peripheral
neuropathy.3
 F wave. The F wave is assessed by supramaximal stimulation of the distal
nerve and can be used to estimate the conduction velocity in the proximal
portion of the nerve.3 This will provide information on the presence of
proximal nerve abnormalities, such as radiculopathy or plexopathy.
 Repetitive nerve stimulation (RNS) studies. RNS studies are intended to evaluate the
integrity and function of the NMJ. The test involves stimulating a nerve repetitively at
variable rates and recording the response of the corresponding muscle(s).3Disorders of
the NMJ will show a diminished muscular response to repetitive stimulation.

Somatosensory evoked potentials (SEP). SEPs evaluate nerve conduction in various
sensory fibers of both the peripheral and central nervous system and are used to test the
integrity and function of these nerve pathways.1 They are typically used to assess
nerve conduction in the spinal cord and other central pathways that cannot be assessed
by standard NCS.

Blink reflexes. The blink reflexes, which are analogs of the corneal reflex, are
evaluated by stimulating the orbicularis orbis muscle at the lower eyelid. They are used
to localize lesions in the fifth or seventh cranial nerves.1
The specific components of an individual test are not standardized. Rather, a differential
diagnosis is developed by the treating physician, and/or the clinician performing the test, and
the specific components of the exam are determined by the disorders that are being considered
in the differential. In addition, the differential diagnosis may be modified during the exam to
reflect initial findings, and this may also influence the specific components that are included in
the final analysis.2
Regulatory Status
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EMG and NCS measure nerve and muscle function and may be indicated when evaluating limb
pain, weakness related to possible spinal nerve compression or other neurologic injury or
disorder.
The EPAD™ by SafeOp Surgical Inc. is the most recent (2014) FDA-approved
electromyographic device. The EPAD is specifically designed for peripheral nerve response
(somatosensory evoked potential [SSEP]) and NMJ monitoring. The CERSR®
Electromyography System by SpineMatrix Inc. is specifically designed for real-time recording
from multiple locations by applying an array of surface electrodes over an anatomic region of
interest. Other FDA-approved myographical devices include: Physical Monitoring Registration
Unit-S (PMRU-S) by Oktx Llc, Myovision 3G Wirefree™ System by Precision Biometrics
Inc., Nuvasive® NV M5 System by Nuvasive Inc., Neuro Omega™ System by Alpha Omega
Engineering Ltd., and the Carefusion Nicolet® EDX by Carefusion 209 Inc. FDA product code:
IKN.
IV. RATIONALE
Top
Assessment of a diagnostic technology typically focuses on 3 categories of evidence: (1)
technical performance (test-retest reliability or interrater reliability); (2) diagnostic accuracy
(sensitivity, specificity, and positive and negative predictive value) in relevant populations of
patients; and (3) demonstration that the diagnostic information can be used to improve patient
outcomes. In addition, subsequent use of a technology outside of the investigational setting may
also be evaluated. These categories of evidence, although not always evaluated in sequence, can
be considered similar to the 4 phases of therapeutic studies.
Technical Performance
There was little recent published evidence on the technical performance of electromyography
(EMG)/nerve conduction studies (NCS). Some research on test-test reliability and validity of
specific EMG components in specific populations was identified.4-8 Two review articles by
Lariviere et al summarized reliability and validity of measures of muscle strength and
endurance.7,8 Correlations of EMG measures with strength and endurance varied by the specific
measure examined, with r values that ranged from 0.39 to 0.81. Test-test reliability was less
variable and on average higher, with intraclass correlations ranging from 0.75 to 0.83. Other
published studies examined methods for improving reliability, for example by attempting to
establish better normalization values for asymptomatic individuals.4,5
It is expected that the performance of the test is operator-dependent and that individuals with
less skill and training will produce less reliable and valid results.1 There was no evidence
identified that examined the difference in results, reliability, or validity by degree of expertise.
Suspected Peripheral Neuropathy or Myopathy
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Diagnostic Accuracy
There is little recent literature on the sensitivity and specificity of EMG/NCS for the diagnosis
of specific neuropathic and myopathic disorders. In general, EMG and NCS are considered the
criterion standard for establishing abnormalities of the electrical system of nerves and muscles,
and the lack of a true reference standard makes research on diagnostic accuracy difficult.
Examples of some representative literature on diagnostic accuracy are reviewed next.
Carpal Tunnel Syndrome
A systematic review of the literature on the diagnosis of carpal tunnel syndrome (CTS) was
performed by the American Academy of Orthopaedic Surgeons in support of their guideline
development process.9 There were a total of 35 studies identified with useful data on diagnostic
accuracy; however, there was a lack of high-quality evidence. There were no prospective
studies identified that enrolled a population of patients similar to that seen in clinical practice.
The following description of the evidence base was made:
The systematic literature review of primary studies indicated that published articles did not
employ a consistent reference standard, few studies evaluated the same diagnostic test, and
most studies enrolled only a few patients. In addition, the majority of primary studies used a
case-control design, which is subject to spectrum bias, thus artificially inflating the
sensitivity and specificity of the evaluated tests. Because of the diversity and suboptimal
design of published studies, no one test could be identified as a “gold standard” for carpal
tunnel syndrome diagnosis.
As a result of the poor quality of evidence, the review concluded that the sensitivity and
specificity of electrodiagnostic assessment for CTS is unknown. Evidence-based
recommendations could not be developed, and all recommendations were therefore rated at a
level V, which is expert opinion.
Some of the individual studies are reviewed next, with emphasis on the larger, more recent, and
methodologically stronger studies. In 2014, Fowler et al evaluated the diagnostic accuracy of
neurodiagnostic studies and ultrasound for CTS, using validated clinical diagnostic criteria as
the reference standard.10 Eighty-five consecutive patients with upper extremity symptoms were
referred for evaluation over a 3-month period at 1 clinic. All patients completed
electrodiagnostic assessment, ultrasound examination, and a validated clinical diagnostic tool
(CTS-6 score). The electrodiagnostic exam was considered positive when there was a distal
motor latency of 4.2 ms or more or a distal sensory latency of 3.2 ms or more. There were 55
patients who were positive for CTS on the CTS-6 clinical score. Using the CTS-6 as the
reference standard, the sensitivity of neurodiagnostic assessment was 89% and the sensitivity
was 80%. That was compared with ultrasound, which had a reported sensitivity of 89% and a
specificity of 90%. This study is limited by the imperfect nature of the reference standard,
which is not a true criterion standard for diagnosis, and which may itself have suboptimal
sensitivity.
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Chang et al examined the sensitivity and specificity of various NCS parameters in 280
consecutive patients (360 hands) with suspected CTS, and 150 normal controls.11 In the 360
hands with suspected CTS, 328 (91.1%) had at least 1 electrodiagnostic abnormality and 8.9%
had normal exams. For individual NCS measures, the sensitivity ranged from 72.5% to 87.2%,
and the specificity ranged from 96.7% to 98.7%. The authors presented algorithms for serial
testing to maximize the sensitivity of the exam.
Homan et al evaluated the agreement between clinical symptoms, physical exam, and
electrodiagnostic studies in 824 individuals with suspected work-related CTS from 6 job
facilities.12 The specific tests used were symptom surveys that included hand diagrams, physical
exam results, and bilateral sensory NCS. The κ value was calculated to determine the degree of
agreement above chance. There were 449 individuals with at least 1 positive finding on any
exam. Of these, only 5% had positive findings on all 3 domains (symptoms, physical exam,
NCS). Overall there was poor agreement between the 3 measures, with κ values ranging from 0
to 0.18.
Lumbar Radiculopathy
The North American Spine Society published evidence-based guidelines on the diagnosis and
treatment of lumbar radiculopathy in 2012.13 A systematic review of the literature was
performed to identify studies of diagnostic accuracy, 1 of which was electrodiagnostic testing.
For the diagnosis of lumbar radiculopathy, the guidelines reviewed 5 studies on diagnostic
accuracy, 2 of which also included a control group of normal individuals. Sensitivities for
various EMG and NCS parameters ranged from 17% to 65%. In the 2 studies that included a
normal control group, specificity for EMG abnormalities was 100% and 87%.
Subsequent to the NASS publication, Mondelli et al published a study in 2013 that evaluated
electrodiagnostic findings in patients with lumbosacral radiculopathy and herniated disc. The
diagnosis of radiculopathy due to herniated disc was made by a combination of clinical
symptoms and magnetic resonance imaging (MRI) results.14 A total of 108 consecutive patients
with monoradiculopathy at L4, L5, or S1 were enrolled from 4 electrodiagnostic laboratories.
There was at least 1 EMG abnormality recorded in 42% of patients, with the most common
abnormality being a delay in the F wave minimum latency. EMG abnormalities could be
predicted on multivariate regression by the presence of clinical symptoms, including muscle
weakness, abnormal reflexes, and the presence of paresthesias.
Peroneal Neuropathy
AENEM published an evidence review in support of practice parameters on the utility of
electrodiagnostic testing for patients with suspected peroneal neuropathy.15 The authors
performed a systematic review of the literature for publications that provided information on the
utility of EMG/NCS. A total of 11 studies met their inclusion criteria, 4 of which were
prospective. Eight studies described use of motor NCS, 8 described use of sensory NCS, and 5
described use of needle EMG. The strongest study design (n=4) used a cohort of patients with
clinically diagnosed peroneal neuropathy and reported the sensitivity of EMG/NCS. The
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sensitivity of EMG/NCS varied widely by the type of measure and the specific area tested,
ranging from 19% to 91%. Specificity was not reported. The authors concluded that certain
NCS parameters were useful for diagnosing peroneal neuropathy and proposed a specific
testing strategy to maximize sensitivity. EMG was not felt to be useful for confirming the
diagnosis of peroneal neuropathy, but may be helpful in excluding alternate diagnoses.
Pediatric Myopathy
Some research has evaluated the accuracy of EMG/NCS compared with muscle biopsy in
children with suspected myopathy. The intent of this line of research is to evaluate whether the
diagnosis can be made with certainty by clinical exam and EMG/NCS, without the need for
muscle biopsy.
Rabie et al evaluated the diagnostic accuracy of EMG compared with muscle biopsy in children
with neuropathies or myopathies.16 The authors retrospectively identified 27 children between
the ages of 6 days to 16 years who had EMG studies, a muscle biopsy, and a final diagnosis
assigned by the treating physician(s). Final diagnoses were congenital myopathy (5 patients),
nonspecific myopathy (6 patients), congenital myasthenic syndrome (3 patients), juvenile
myasthenia gravis (1 patient), arthrogryposis multiplex congenital (2 patients), hereditary motor
and sensory neuropathy (1 patient), bilateral peroneal neuropathies (1 patient), and normal (8
patients). In general, the sensitivity of EMG for detecting abnormalities implied by the final
diagnosis was low. For example, the sensitivity of EMG for detecting myopathic motor unit
potentials in any myopathy was 47% (7/15), and the sensitivity for congenital myopathies was
40% (2/5). The sensitivity was especially low for patients younger than 2 years of age
compared with older children, but this comparison is limited by very low numbers of patients in
each group.
Ghosh et al performed a retrospective chart review of 227 patients who received EMG studies
between the years of 2009-2013.11 There were 72 patients (32%) who also received muscle
biopsy, and these 72 patients constituted the study group. The criterion standard was myopathy
confirmed either by muscle biopsy or genetic testing. The overall sensitivity of EMG was 91%,
with the most commonly missed diagnosis being metabolic myopathy. The overall specificity
was 67%. This low specificity, which is lower than most other reports of specificity, raises the
question of whether the sensitivity of muscle biopsy is lower than expected, thus resulting in
EMG results that are true positives being classified as false positives.
Section Summary: Suspected Peripheral Neuropathy or Myopathy
EMG/NCS is generally considered to be a specific, but not a sensitive test. However, the
evidence on diagnostic accuracy of EMG/NCS is poor, in part because of the lack of a true
reference standard. In the scattered evidence that was identified, sensitivity was often less than
50%, and specificity was most commonly in the range of 80% to 100%. Because of the small
quantity and poor quality of the evidence, precise estimates of sensitivity and specificity for
specific disorders cannot be made.
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Evaluation of Current Clinical Practice Guidelines
The lack of high-quality evidence on the clinical utility of EMG/NCS is reflected by the lack of
evidence-based guidelines. Most existing guidelines rely on expert consensus. This section will
review some of the available guidelines, with a focus on the degree to which they are evidencebased and whether the recommendations are consistent across different guideline bodies.
Guidelines from 3 organizations will be examined here, focusing on the methods of the
development process, and the rigor of evidence review. The 3 organizations are the American
Association of Neuromuscular and Neurodiagnostic Medicine (AANEM), American Academy
of Neurology (AAN), and American Academy of Orthopaedic Surgeons (AAOS) (CTS only).
The subsequent section on “Practice Guidelines and Position Statements” summarizes the
recommendations of the guidelines.
AANEM published a document titled “Recommended Policy for Electrodiagnostic Medicine”
in 1999.2 This document is a Position Statement based on consensus of experts in the field. A
consensus conference was held in which 43 experts in the field of electrodiagnostic medicine
were invited. No information was given regarding the selection process for these individuals,
but it was noted that they were either neurologists or physiatrists who represented a diversity of
practice types and locations. Members of AANEM who participated included the board of
directors, professional practice committee members, other committee chairs. Physicians from
both academic medical centers and from private practice were included. Further details about
the process of literature review, and/or the process for group decision making, was not
provided.
AAOS published clinical practice guidelines on the diagnosis and treatment of CTS in 2007.17
The following statement was made regarding the methodology of these guidelines:
The AAOS Carpal Tunnel Syndrome (CTS) Guideline Work Group systematically
reviewed the available literature, evaluated the level of evidence found in that literature, and
subsequently wrote the following recommendations based on a rigorous, standardized
consensus process.
Multiple iterations of written review were conducted by the participating Work Group,
AAOS Guidelines Oversight Committee, AAOS Evidence-based Practice Committee, and
the AAOS Council on Research, Quality Assessment, and Technology prior to final
approval by the AAOS Board of Directors.
Voting and reaching consensus on guideline recommendations was conducted using a
modification of the nominal group technique. In this modification each Work Group member
ranked a recommendation or performance measure on a scale ranging from 1 (extremely
appropriate) to 9 (extremely inappropriate). Consensus was obtained; 6 of 7 Work Group
members ranked the recommendation or measure as a 7, 8, or 9. If at least 2 work group
members did not assign a rank of 7, 8, or 9, an iterative process was used to resolve
disagreements. If disagreements were not resolved after several rounds of discussion, no
recommendation was adopted.
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AAN published a position statement on electrodiagnostic assessment in 2004.18 According to
AAN, “A position statement is a concise explanation of AAN’s position on a certain issue that
includes background information and the rationale behind the Academy’s position. The position
statement, generally not exceeding 1,000 words, is in-depth and must reference all supporting
evidence.” The AAN document on EMG did not contain any description of literature review,
nor were there references accompanying the recommendations.
Section Summary: Clinical Practice Guidelines
The existing guidelines from these major specialty societies consist primarily of expert
consensus. For guidelines in which an evidence review was performed, such as the AAOS
guidelines, the evidence was not sufficient to make evidence-based recommendations. All 3 of
these societies make general recommendations as to the utility of electrodiagnostic testing as an
adjunct to diagnosis for myopathic and neuropathic disorders. None of the guidelines offer
detailed indications for patient testing by diagnosis.
Ongoing and Unpublished Clinical Trials
A search of ClinicalTrials.gov in June 2015 did not identify any ongoing or unpublished trials
that would likely influence this review.
Summary of Evidence
The evidence for the accuracy of electrodiagnostic assessment in patients with signs and
symptoms of neuropathy or myopathy includes scattered small studies on a few diagnoses, such
as carpal tunnel syndrome, radiculopathy, and myopathy. Relevant outcomes are the sensitivity,
specificity, predictive values, and related measures of diagnostic accuracy. There are several
challenges to obtaining high-quality evidence of this type. Most prominently, electrodiagnostic
assessment is considered to be the criterion standard for evaluating the electrical function of
peripheral nerves and muscles. Because of the lack of a true alternative reference standard, it is
difficult to perform high-quality studies on diagnostic accuracy. As a result, the sensitivity and
specificity of particular electromyography (EMG) and nerve conduction studies (NCS)
abnormalities for particular clinical disorders cannot be determined. In general, these tests are
considered to be more specific than sensitive, and normal results do not rule out disease. For the
available evidence on specific diagnoses, studies report a wide range of sensitivities, which are
often less than 50%. The specificity is expected to be considerably higher, but the data are not
sufficient to provide precise estimates of either sensitivity or specificity. Therefore, the
evidence is insufficient to determine the effects of the technology on health outcomes.
Practice Guidelines and Position Statements
The American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
published 2 position statements on recommended coverage policy for EMG/NCS. The first,
titled “Recommended policy for electrodiagnostic medicine”, was initially published in 1999
with the latest update performed in 2004.
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The second AANEM document regarding coverage policy, titled “Model Policy for Needle
Electromyography and Nerve Conduction Studies,” was published in 2010.19 This document
made the following specific recommendations for testing:

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

Focal neuropathies, entrapment neuropathies, or compressive lesions/syndromes such as
carpal tunnel syndrome, ulnar neuropathies, or root lesions, for localization
Traumatic nerve lesions, for diagnosis and prognosis
Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic,
uremic, metabolic, or immune
Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as
myasthenia gravis, myasthenic syndrome
Symptom-based presentations such as “pain in limb,” weakness, disturbance in skin
sensation or “paresthesia” when appropriate pretest evaluations are inconclusive and the
clinical assessment unequivocally supports the need for the study
Radiculopathy-cervical, lumbosacral
Polyneuropathy-metabolic, degenerative, hereditary
Plexopathy-idiopathic, trauma, infiltration
Myopathy-including polymyositis and dermatomyositis, myotonic, and congenital
myopathies
Precise muscle location for injections such as botulinum toxin, phenol, etc.
This document also listed situations that were considered investigational, these were:
 EDX [electrodiagnostic] testing with automated, noninvasive nerve conduction testing
devices
 Screening testing for polyneuropathy of diabetes or end-stage renal disease (ESRD)
 Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these
two conditions also is not covered.
 Psychophysical measurements (current, vibration, thermal perceptions), even though they
may involve delivery of a stimulus, are not covered.
 Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT)
 Examination using portable hand-held devices, which are incapable of real-time wave-form
display and analysis
AANEM published practice parameters on the utility of EMG/NCS for the diagnosis of
peroneal neuropathy.15 This was an evidence-based review, focusing on the questions of
whether EMG/NCS are useful in diagnosing peroneal neuropathy, and/or in determining
prognosis. The following recommendations were made:
In patients with suspected peroneal neuropathy, the following electrodiagnostic studies are
possibly useful, to make or confirm the diagnosis:
 Motor NCSs of the peroneal nerve recording from the AT and EDB muscles (Level C
recommendation, class III evidence)
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
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

Orthodromic and antidromic superficial peroneal sensory NCS (Level C recommendation,
class III evidence)
At least one additional normal motor and sensory NCS in the same limb, to assure that the
peroneal neuropathy is isolated, and not part of a more widespread local or systemic
neuropathy.
Data are insufficient to determine the role of needle EMG in making the diagnosis of
peroneal neuropathy. (Level U recommendation, class IV evidence). However,
abnormalities on needle examination outside of the distribution of the peroneal nerve
should suggest alternative diagnoses (Expert opinion).
In patients with confirmed peroneal neuropathy, EDX studies are possibly useful in
providing prognostic information, with regards to recovery of function (Level C
recommendation, class III and IV evidence.
The American Academy of Orthopaedic Surgeons (AAOS) issued a 2007 clinical guideline on
the diagnosis of carpel tunnel syndrome.17 The guideline makes the following
recommendations:




Recommendation 3.1a. The physician may obtain electrodiagnostic tests to differentiate
among diagnoses. (Level V, Grade C)
Recommendation 3.1b. The physician may obtain electrodiagnostic tests in the presence of
thenar atrophy and/or persistent numbness (Level V, Grade C).
Recommendation 3.1c. The physician should obtain electrodiagnostic tests if clinical
and/or provocative tests are positive and surgical management is being considered (Level
II and III, Grade B)
Recommendation 3.2. If the physician orders electrodiagnostic tests, the testing protocol
should follow the AAN/AANEM/AAPMR guidelines for diagnosis of CTS (Level IV and
V, Grade C).
An American Academy of Neurology (AAN) position statement on diagnostic
electromyography in the practice of medicine, 200418 states the following:



Clinical needle electromyography (EMG) is an invasive medical procedure during which
the physician inserts an electrode into a patient's muscles to diagnose the cause of muscle
weakness. Needle EMG allows physicians to distinguish a wide range of conditions, from
carpal tunnel syndrome to ALS (Lou Gehrig disease).
Needle EMG is also an integral component of the neurological examination that cannot be
separated from the physician’s evaluation of the patient. The test is dynamic and depends
upon the visual, tactile, and audio observations of the examiner. There is no way for
physicians to independently verify the accuracy of reports performed by non-physicians.
Misdiagnosis can mean delayed or inappropriate treatment (including surgery) and
diminished quality of life. Because needle EMG is strictly diagnostic, the procedure
clearly and exclusively falls within the practice of medicine.
Page 14
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063

The AAN supports working through regulatory and legislative channels to define this
procedure as the practice of medicine. Such definition would help ensure the highest
standards patient care, patient safety and cost-effectiveness in the performance of
diagnostic EMG.
A consensus statement on diagnosing multifocal motor neuropathy from AANEM20 states:
Multifocal motor neuropathy is a diagnosis that is based on recognition of a characteristic
pattern of clinical symptoms, clinical signs, and electrodiagnostic findings. The fundamental
electrodiagnostic finding is partial conduction block of motor axons.
An online information page on electrodiagnostic testing from AAOS, OrthoInfo, 200721
provides the following information:
An EMG records and analyzes the electrical activity in your muscles. It is used to learn more
about the functioning of nerves in the arms and legs. When a normal muscle is at rest, it is
electrically silent.
NCS are often done along with the EMG to determine if a nerve is functioning normally. The
doctor conducting the test will tape wires (electrodes) to the skin in various places along the
nerve pathway. Then the doctor stimulates the nerve with an electric current. As the current
travels down the nerve pathway, the electrodes placed along the way capture the signal and
time how fast the signal is traveling. In healthy nerves, electrical signals can travel at up to
120 miles per hour. If the nerve is damaged, however, the signal will be slower and weaker.
By stimulating the nerve at various places, the doctor can determine the specific site of the
injury. Nerve conduction studies also may be used during treatment to test the progress being
made.
The accuracy of electrodiagnostic tests depends on the skill of the person conducting the test
and the precision of the equipment used. Generally, these tests can accurately determine
injuries to the nerves or nerve roots as well as diseases of the nerves and muscles. In some
conditions, however, it may take several weeks for changes to become apparent. Additionally,
the tests cannot determine the existence or extent of pain. A person may still feel pain or
exhibit symptoms even though electrodiagnostic tests show that the nerves are functioning
normally. In these cases, your orthopaedist will recommend a course of treatment for you.
The North American Spine Society published guidelines on the diagnosis and treatment of
lumbar disc herniation in 2012.13 This document made the following statement about the use of
EMG/NCS for diagnosis of lumbar disc herniation:
Electromyography, nerve conduction studies and F-waves are suggested to have limited utility
in the diagnosis of lumbar disc herniation with radiculopathy. H-reflexes can be helpful in the
diagnosis of an S1 radiculopathy, though are not specific to the diagnosis of lumbar disc
herniation. (Grade of Recommendation: B)
Page 15
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
The Institute for Clinical Systems Improvement published guidelines on the assessment and
management of chronic pain in 2013.22 These guidelines made the following statement about
the use of EMG/NCS:
Electromyography and nerve conduction studies are of use in patients suspected of having
lower motor neuron dysfunction, nerve or nerve root pathology, or myopathy [Low Quality
Evidence].
U.S. Preventive Services Task Force Recommendations
Not applicable.
Medicare National Coverage
Sensory Nerve Conduction Threshold Tests (sNCTs) (160.23). This procedure is different and
distinct from assessment of nerve conduction velocity, amplitude and latency. It is also different
from short-latency somatosensory evoked potentials.
Effective October 1, 2002, CMS initially concluded that there was insufficient scientific or
clinical evidence to consider the sNCT test and the device used in performing this test
reasonable and necessary within the meaning of section 1862(a)(1)(A) of the law. Therefore,
sNCT was noncovered.
Effective April 1, 2004, based on a reconsideration of current Medicare policy for sNCT, CMS
concludes that the use of any type of sNCT device (eg, “current output” type device used to
perform current perception threshold [CPT], pain perception threshold [PPT], or pain tolerance
threshold [PTT] testing or “voltage input” type device used for voltage-nerve conduction
threshold (v-NCT) testing) to diagnose sensory neuropathies or radiculopathies in Medicare
beneficiaries is not reasonable and necessary.23
V. DEFINITIONS
Top
510 (k) is a premarketing submission made to FDA to demonstrate that the device to be
marketed is as safe and effective, that is, substantially equivalent (SE), to a legally marketed
device that is not subject to premarket approval (PMA). Applicants must compare their
510(k) device to one or more similar devices currently on the U.S. market and make and
support their substantial equivalency claims.
NEUROPATHY refers to any disease of the nerves.
PERIPHERAL refers to something that occurs away from the center.
TRANSCUTANEOUS refers to a procedure that is performed through the skin.
Page 16
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
VI. BENEFIT VARIATIONS
Top
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits. A
member’s individual or group customer benefits govern which services are covered, which
are excluded, and which are subject to benefit limits and which require preauthorization.
Members and providers should consult the member’s benefit information or contact Capital
for benefit information.
VII. DISCLAIMER
Top
Capital’s medical policies are developed to assist in administering a member’s benefits, do not constitute
medical advice and are subject to change. Treating providers are solely responsible for medical advice and
treatment of members. Members should discuss any medical policy related to their coverage or condition with
their provider and consult their benefit information to determine if the service is covered. If there is a
discrepancy between this medical policy and a member’s benefit information, the benefit information will
govern. Capital considers the information contained in this medical policy to be proprietary and it may only be
disseminated as permitted by law.
VIII. CODING INFORMATION
Top
Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The
identification of a code in this section does not denote coverage as coverage is determined by the
terms of member benefit information. In addition, not all covered services are eligible for
separate reimbursement.
Covered when medically necessary:
CPT Codes®
92265
95869
95909
95860
95870
95910
95861
95872
95911
95863
95874
95912
95864
95885
95913
95865
95886
95937
95866
95887
95867
95907
95868
95908
Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved.
Page 17
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
A52.15
E08.40
E08.41
E08.42
E08.43
E08.44
E08.49
E08.610
E09.40
E09.41
E09.42
E09.43
E09.44
E09.49
E09.610
E10.40
E10.41
E10.42
E10.43
E10.44
E10.49
E10.610
E11.40
E11.41
E11.42
E11.43
E11.44
Description
Late syphilitic neuropathy
Diabetes mellitus due to underlying condition with diabetic neuropathy,
unspecified
Diabetes mellitus due to underlying condition with diabetic mononeuropathy
Diabetes mellitus due to underlying condition with diabetic polyneuropathy
Diabetes mellitus due to underlying condition with diabetic autonomic
(poly)neuropathy
Diabetes mellitus due to underlying condition with diabetic amyotrophy
Diabetes mellitus due to underlying condition with other diabetic neurological
complication
Diabetes mellitus due to underlying condition with diabetic neuropathic
arthropathy
Drug or chemical induced diabetes mellitus with neurological complications
with diabetic neuropathy, unspecified
with diabetic mononeuropathy
with diabetic polyneuropathy
with diabetic autonomic (poly)neuropathy
with diabetic amyotrophy
with other diabetic neurological complication
Drug or chemical induced diabetes mellitus with diabetic neuropathic
arthropathy
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
Type 1 diabetes mellitus with diabetic mononeuropathy
Type 1 diabetes mellitus with diabetic polyneuropathy
Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy
Type 1 diabetes mellitus with diabetic amyotrophy
Type 1 diabetes mellitus with other diabetic neurological complication
Type 1 diabetes mellitus with diabetic neuropathic arthropathy
Page 18
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
E11.49
E11.610
E13.40
E13.41
E13.42
E13.43
E13.44
E13.49
E13.610
G12.20
G12.21
G12.22
G12.29
G12.8
G13.0
G13.1
G54.0
G54.1
G54.2
G54.3
G54.4
G54.8
G54.9
G55
G56.00
G56.01
G56.02
G56.10
G56.11
G56.12
G56.20
G56.21
G56.22
G56.30
G56.31
G56.32
Description
Other specified diabetes mellitus with diabetic neuropathy, unspecified
Other specified diabetes mellitus with diabetic mononeuropathy
Other specified diabetes mellitus with diabetic polyneuropathy
Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
Other specified diabetes mellitus with diabetic amyotrophy
Other specified diabetes mellitus with other diabetic neurological complication
Other specified diabetes mellitus with diabetic neuropathic arthropathy
Motor neuron disease, unspecified
Amyotrophic lateral sclerosis
Progressive bulbar palsy
Other motor neuron disease
Other spinal muscular atrophies and related syndromes
Paraneoplastic neuromyopathy and neuropathy
Other systemic atrophy primarily affecting central nervous system in neoplastic
disease
Brachial plexus disorders
Lumbosacral plexus disorders
Cervical root disorders, not elsewhere classified
Thoracic root disorders, not elsewhere classified
Lumbosacral root disorders, not elsewhere classified
Other nerve root and plexus disorders
Nerve root and plexus disorder, unspecified
Nerve root and plexus compressions in diseases classified elsewhere
Carpal tunnel syndrome, unspecified upper limb
Carpal tunnel syndrome, right upper limb
Carpal tunnel syndrome, left upper limb
Other lesions of median nerve, unspecified upper limb
Other lesions of median nerve, right upper limb
Other lesions of median nerve, left upper limb
Lesion of ulnar nerve, unspecified upper limb
Lesion of ulnar nerve, right upper limb
Lesion of ulnar nerve, left upper limb
Lesion of radial nerve, unspecified upper limb
Lesion of radial nerve, right upper limb
Lesion of radial nerve, left upper limb
Page 19
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
G56.40
G56.41
G56.42
G56.80
G56.81
G56.82
G56.90
G56.91
G56.92
G57.00
G57.01
G57.02
G57.10
G57.11
G57.12
G57.20
G57.21
G57.22
G57.30
G57.31
G57.32
G57.40
G57.41
G57.42
G57.50
G57.51
G57.52
G57.60
G57.61
G57.62
G57.70
G57.71
G57.72
G57.80
G57.81
G57.82
G57.90
Description
Causalgia of unspecified upper limb
Causalgia of right upper limb
Causalgia of left upper limb
Other specified mononeuropathies of unspecified upper limb
Other specified mononeuropathies of right upper limb
Other specified mononeuropathies of left upper limb
Unspecified mononeuropathy of unspecified upper limb
Unspecified mononeuropathy of right upper limb
Unspecified mononeuropathy of left upper limb
Lesion of sciatic nerve, unspecified lower limb
Lesion of sciatic nerve, right lower limb
Lesion of sciatic nerve, left lower limb
Meralgia paresthetica, unspecified lower limb
Meralgia paresthetica, right lower limb
Meralgia paresthetica, left lower limb
Lesion of femoral nerve, unspecified lower limb
Lesion of femoral nerve, right lower limb
Lesion of femoral nerve, left lower limb
Lesion of lateral popliteal nerve, unspecified lower limb
Lesion of lateral popliteal nerve, right lower limb
Lesion of lateral popliteal nerve, left lower limb
Lesion of medial popliteal nerve, unspecified lower limb
Lesion of medial popliteal nerve, right lower limb
Lesion of medial popliteal nerve, left lower limb
Tarsal tunnel syndrome, unspecified lower limb
Tarsal tunnel syndrome, right lower limb
Tarsal tunnel syndrome, left lower limb
Lesion of plantar nerve, unspecified lower limb
Lesion of plantar nerve, right lower limb
Lesion of plantar nerve, left lower limb
Causalgia of unspecified lower limb
Causalgia of right lower limb
Causalgia of left lower limb
Other specified mononeuropathies of unspecified lower limb
Other specified mononeuropathies of right lower limb
Other specified mononeuropathies of left lower limb
Unspecified mononeuropathy of unspecified lower limb
Page 20
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
G57.91
G57.92
G58.0
G58.7
G58.9
G59
G60.0
G60.1
G60.2
G60.3
G60.8
G60.9
G61.0
G61.1
G61.81
G61.89
G61.9
G62.0
G62.1
G62.2
G62.81
G62.82
G62.89
G62.9
G63
G64
G70.00
G70.01
G70.1
G70.2
G70.80
G70.81
G70.89
G70.9
G71.0
G71.11
G71.12
Description
Unspecified mononeuropathy of right lower limb
Unspecified mononeuropathy of left lower limb
Intercostal neuropathy
Mononeuritis multiplex
Mononeuropathy, unspecified
Mononeuropathy in diseases classified elsewhere
Hereditary motor and sensory neuropathy
Refsum's disease
Neuropathy in association with hereditary ataxia
Idiopathic progressive neuropathy
Other hereditary and idiopathic neuropathies
Hereditary and idiopathic neuropathy, unspecified
Guillain-Barre syndrome
Serum neuropathy
Chronic inflammatory demyelinating polyneuritis
Other inflammatory polyneuropathies
Inflammatory polyneuropathy, unspecified
Drug-induced polyneuropathy
Alcoholic polyneuropathy
Polyneuropathy due to other toxic agents
Critical illness polyneuropathy
Radiation-induced polyneuropathy
Other specified polyneuropathies
Polyneuropathy, unspecified
Polyneuropathy in diseases classified elsewhere
Other disorders of peripheral nervous system
Myasthenia gravis without (acute) exacerbation
Myasthenia gravis with (acute) exacerbation
Toxic myoneural disorders
Congenital and developmental myasthenia
Lambert-Eaton syndrome, unspecified
Lambert-Eaton syndrome in disease classified elsewhere
Other specified myoneural disorders
Myoneural disorder, unspecified
Muscular dystrophy
Myotonic muscular dystrophy
Myotonia congenita
Page 21
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
G71.13
G71.14
G71.19
G71.2
G71.3
G72.0
G72.1
G72.2
G72.3
G72.41
G72.49
G72.81
G72.89
G72.9
G73.1
G73.3
G73.7
G90.01
G90.09
G90.2
G90.4
G90.50
G90.511
G90.512
G90.513
G90.519
G90.521
G90.522
G90.523
G90.529
G90.59
G90.8
G90.9
G99.0
M05.40
M05.411
M05.412
Description
Myotonic chondrodystrophy
Drug induced myotonia
Other specified myotonic disorders
Congenital myopathies
Mitochondrial myopathy, not elsewhere classified
Drug-induced myopathy
Alcoholic myopathy
Myopathy due to other toxic agents
Periodic paralysis
Inclusion body myositis [IBM]
Other inflammatory and immune myopathies, not elsewhere classified
Critical illness myopathy
Other specified myopathies
Myopathy, unspecified
Lambert-Eaton syndrome in neoplastic disease
Myasthenic syndromes in other diseases classified elsewhere
Myopathy in diseases classified elsewhere
Carotid sinus syncope
Other idiopathic peripheral autonomic neuropathy
Horner's syndrome
Autonomic dysreflexia
Complex regional pain syndrome I, unspecified
Complex regional pain syndrome I of right upper limb
Complex regional pain syndrome I of left upper limb
Complex regional pain syndrome I of upper limb, bilateral
Complex regional pain syndrome I of unspecified upper limb
Complex regional pain syndrome I of right lower limb
Complex regional pain syndrome I of left lower limb
Complex regional pain syndrome I of lower limb, bilateral
Complex regional pain syndrome I of unspecified lower limb
Complex regional pain syndrome I of other specified site
Other disorders of autonomic nervous system
Disorder of the autonomic nervous system, unspecified
Autonomic neuropathy in diseases classified elsewhere
Rheumatoid myopathy with rheumatoid arthritis of unspecified site
Rheumatoid myopathy with rheumatoid arthritis of right shoulder
Rheumatoid myopathy with rheumatoid arthritis of left shoulder
Page 22
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
M05.419
M05.421
M05.422
M05.429
M05.431
M05.432
M05.439
M05.441
M05.442
M05.449
M05.451
M05.452
M05.459
M05.461
M05.462
M05.469
M05.471
M05.472
M05.479
M05.49
M05.50
M05.511
M05.512
M05.519
M05.521
M05.522
M05.529
M05.531
M05.532
M05.539
M05.541
M05.542
M05.549
M05.551
M05.552
M05.559
M05.561
Description
Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder
Rheumatoid myopathy with rheumatoid arthritis of right elbow
Rheumatoid myopathy with rheumatoid arthritis of left elbow
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow
Rheumatoid myopathy with rheumatoid arthritis of right wrist
Rheumatoid myopathy with rheumatoid arthritis of left wrist
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
Rheumatoid myopathy with rheumatoid arthritis of right hand
Rheumatoid myopathy with rheumatoid arthritis of left hand
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
Rheumatoid myopathy with rheumatoid arthritis of right hip
Rheumatoid myopathy with rheumatoid arthritis of left hip
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
Rheumatoid myopathy with rheumatoid arthritis of right knee
Rheumatoid myopathy with rheumatoid arthritis of left knee
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of multiple sites
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
Page 23
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
M05.562
M05.569
M05.571
M05.572
M05.579
M05.59
M33.00
M33.01
M33.02
M33.09
M33.10
M33.11
M33.12
M33.19
M33.20
M33.21
M33.22
M33.22
M33.29
M33.90
M33.91
M33.92
M33.99
M34.82
M34.83
M35.03
M36.0
M51.14
M51.15
M51.16
M51.17
M54.11
M54.12
M54.13
M54.14
M54.15
Description
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and
foot
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
Juvenile dermatopolymyositis, organ involvement unspecified
Juvenile dermatopolymyositis with respiratory involvement
Juvenile dermatopolymyositis with myopathy
Juvenile dermatopolymyositis with other organ involvement
Other dermatopolymyositis, organ involvement unspecified
Other dermatopolymyositis with respiratory involvement
Other dermatopolymyositis with myopathy
Other dermatopolymyositis with other organ involvement
Polymyositis, organ involvement unspecified
Polymyositis with respiratory involvement
Polymyositis with myopathy
Polymyositis with other organ involvement
Dermatopolymyositis, unspecified, organ involvement unspecified
Dermatopolymyositis, unspecified with respiratory involvement
Dermatopolymyositis, unspecified with myopathy
Dermatopolymyositis, unspecified with other organ involvement
Systemic sclerosis with myopathy
Systemic sclerosis with polyneuropathy
Sicca syndrome with myopathy
Dermato(poly)myositis in neoplastic disease
Intervertebral disc disorders with radiculopathy, thoracic region
Intervertebral disc disorders with radiculopathy, thoracolumbar region
Intervertebral disc disorders with radiculopathy, lumbar region
Intervertebral disc disorders with radiculopathy, lumbosacral region
Radiculopathy, occipito-atlanto-axial region
Radiculopathy, cervical region
Radiculopathy, cervicothoracic region
Radiculopathy, thoracic region
Radiculopathy, thoracolumbar region
Page 24
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
M54.16
M54.17
S04.10XA
S04.11XA
S04.12XA
S04.20XA
S04.21XA
S04.22XA
S04.30XA
S04.31XA
S04.32XA
S04.40XA
S04.41XA
S04.42XA
S04.50XA
S04.51XA
S04.52XA
S04.60XA
S04.61XA
S04.62XA
S04.70XA
S04.71XA
S04.72XA
S04.811A
S04.812A
S04.819A
S04.891A
S04.892A
S04.899A
S04.9XXA
S12.000A
S12.000B
S12.001A
Description
Radiculopathy, lumbar region
Radiculopathy, lumbosacral region
Injury of oculomotor nerve, unspecified side, initial encounter
Injury of oculomotor nerve, right side, initial encounter
Injury of oculomotor nerve, left side, initial encounter
Injury of trochlear nerve, unspecified side, initial encounter
Injury of trochlear nerve, right side, initial encounter
Injury of trochlear nerve, left side, initial encounter
Injury of trigeminal nerve, unspecified side, initial encounter
Injury of trigeminal nerve, right side, initial encounter
Injury of trigeminal nerve, left side, initial encounter
Injury of abducent nerve, unspecified side, initial encounter
Injury of abducent nerve, right side, initial encounter
Injury of abducent nerve, left side, initial encounter
Injury of facial nerve, unspecified side, initial encounter
Injury of facial nerve, right side, initial encounter
Injury of facial nerve, left side, initial encounter
Injury of acoustic nerve, unspecified side, initial encounter
Injury of acoustic nerve, right side, initial encounter
Injury of acoustic nerve, left side, initial encounter
Injury of accessory nerve, unspecified side, initial encounter
Injury of accessory nerve, right side, initial encounter
Injury of accessory nerve, left side, initial encounter
Injury of olfactory [1st ] nerve, right side, initial encounter
Injury of olfactory [1st ] nerve, left side, initial encounter
Injury of olfactory [1st ] nerve, unspecified side, initial encounter
Injury of other cranial nerves, right side, initial encounter
Injury of other cranial nerves, left side, initial encounter
Injury of other cranial nerves, unspecified side, initial encounter
Injury of unspecified cranial nerve, initial encounter
Unspecified displaced fracture of first cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of first cervical vertebra, initial encounter for
closed fracture
Page 25
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S12.001B
S12.100A
S12.100B
S12.101A
S12.101B
S12.200A
S12.200B
S12.201A
S12.201B
S12.300A
S12.300B
S12.301A
S12.301B
S12.400A
S12.400B
S12.401A
S12.401B
S12.500A
S12.500B
Description
open fracture
Unspecified displaced fracture of second cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of second cervical vertebra, initial encounter
for closed fracture
for open fracture
Unspecified displaced fracture of third cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of third cervical vertebra, initial encounter
for closed fracture
for open fracture
Unspecified displaced fracture of fourth cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of fourth cervical vertebra, initial encounter
for closed fracture
for open fracture
Unspecified displaced fracture of fifth cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of fifth cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified displaced fracture of sixth cervical vertebra, initial encounter for
closed fracture
open fracture
Page 26
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S12.501A
S12.501B
S12.600A
S12.600B
S12.601A
S12.601B
S12.9XXA
S14.0XXA
S14.101A
S14.102A
S14.103A
S14.104A
S14.105A
S14.106A
S14.107A
S14.108A
S14.109A
S14.111A
S14.112A
S14.113A
S14.114A
S14.115A
S14.116A
S14.117A
S14.118A
S14.119A
S14.121A
S14.122A
S14.123A
S14.124A
S14.125A
Description
Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter
for closed fracture
for open fracture
Unspecified displaced fracture of seventh cervical vertebra, initial encounter for
closed fracture
open fracture
Unspecified nondisplaced fracture of seventh cervical vertebra, initial encounter
for closed fracture
for open fracture
Fracture of neck, unspecified, initial encounter
Concussion and edema of cervical spinal cord, initial encounter
Unspecified injury at C1 level of cervical spinal cord, initial encounter
Unspecified injury at unspecified level of cervical spinal cord, initial encounter
Complete lesion at C1 level of cervical spinal cord, initial encounter
Complete lesion at unspecified level of cervical spinal cord, initial encounter
Central cord syndrome at C1 level of cervical spinal cord, initial encounter
Page 27
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S14.126A
S14.127A
S14.128A
S14.129A
S14.131A
S14.132A
S14.133A
S14.134A
S14.135A
S14.136A
S14.137A
S14.138A
S14.139A
S14.141A
S14.142A
S14.143A
S14.144A
S14.145A
S14.146A
S14.147A
S14.148A
S14.149A
S14.151A
S14.152A
S14.153A
S14.154A
S14.155A
S14.156A
S14.157A
S14.158A
S14.159A
S14.2XXA
S14.4XXA
Description
Central cord syndrome at unspecified level of cervical spinal cord, initial
encounter
Anterior cord syndrome at C1 level of cervical spinal cord, initial encounter
Anterior cord syndrome at unspecified level of cervical spinal cord, initial
encounter
Brown-Sequard syndrome at C1 level of cervical spinal cord, initial encounter
Brown-Sequard syndrome at unspecified level of cervical spinal cord, initial
encounter
Other incomplete lesion at C1 level of cervical spinal cord, initial encounter
Other incomplete lesion at unspecified level of thoracic spinal cord, initial
encounter
Injury of nerve root of cervical spine, initial encounter
Injury of peripheral nerves of neck, initial encounter
Page 28
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S14.5XXA
S14.8XXA
S14.9XXA
S22.009A
S22.009B
S22.019A
S22.019B
S22.029A
S22.029B
S22.039A
S22.039B
S22.049A
S22.049B
S22.059A
S22.059B
S22.069A
S22.069B
S22.079A
S22.079B
S22.089A
S22.089B
S24.0XXA
S24.101A
S24.102A
S24.103A
S24.104A
S24.109A
S24.109D
Description
Injury of cervical sympathetic nerves, initial encounter
Injury of other specified nerves of neck, initial encounter
Injury of unspecified nerves of neck, initial encounter
Unspecified fracture of unspecified thoracic vertebra, initial encounter for
closed fracture
Unspecified fracture of unspecified thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of first thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of first thoracic vertebra, initial encounter for open fracture
Unspecified fracture of second thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of second thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of third thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of third thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of fourth thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of fourth thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of T5-T6 vertebra, initial encounter for closed fracture
Unspecified fracture of T5-T6 vertebra, initial encounter for open fracture
Concussion and edema of thoracic spinal cord, initial encounter
Unspecified injury at T1 level of thoracic spinal cord, initial encounter
Unspecified injury at T2-T6 level of thoracic spinal cord, initial encounter
Unspecified injury at unspecified level of thoracic spinal cord, initial encounter
Unspecified injury at unspecified level of thoracic spinal cord, subsequent
encounter
Page 29
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S24.109S
S24.111A
S24.112A
S24.113A
S24.114A
S24.119A
S24.131A
S24.132A
S24.133A
S24.134A
S24.139A
S24.141A
S24.142A
S24.143A
S24.144A
S24.149A
S24.151A
S24.152A
S24.153A
S24.154A
S24.159A
S24.2XXA
S24.3XXA
S24.4XXA
S24.8XXA
S24.9XXA
S32.009A
Description
Unspecified injury at unspecified level of thoracic spinal cord, sequela
Complete lesion at T1 level of thoracic spinal cord, initial encounter
Complete lesion at T2-T6 level of thoracic spinal cord, initial encounter
Complete lesion at unspecified level of thoracic spinal cord, initial encounter
Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter
Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounter
Anterior cord syndrome at T7-T10 level of thoracic spinal cord, initial
encounter
encounter
Anterior cord syndrome at unspecified level of thoracic spinal cord, initial
encounter
Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounter
Brown-Sequard syndrome at T2-T6 level of thoracic spinal cord, initial
encounter
encounter
encounter
Brown-Sequard syndrome at unspecified level of thoracic spinal cord, initial
encounter
Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter
Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounter
Other incomplete lesion at T7-T10 level of thoracic spinal cord, initial
encounter
encounter
encounter
Injury of nerve root of thoracic spine, initial encounter
Injury of peripheral nerves of thorax, initial encounter
Injury of thoracic sympathetic nervous system, initial encounter
Injury of other specified nerves of thorax, initial encounter
Injury of unspecified nerve of thorax, initial encounter
Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed
fracture
Page 30
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S32.009B
S32.019A
S32.019B
S32.029A
S32.029B
S32.039A
S32.039B
S32.049A
S32.049B
S32.059A
S32.059B
S32.10XA
S32.10XB
S32.2XXA
S32.2XXB
S34.01XA
S34.02XA
S34.101A
S34.102A
S34.103A
S34.104A
S34.105A
S34.109A
S34.111A
S34.112A
S34.113A
S34.114A
S34.115A
S34.119A
S34.121A
Description
Unspecified fracture of unspecified lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of first lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of first lumbar vertebra, initial encounter for open fracture
Unspecified fracture of second lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of second lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of third lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of third lumbar vertebra, initial encounter for open fracture
Unspecified fracture of fourth lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of fourth lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of fifth lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of fifth lumbar vertebra, initial encounter for open fracture
Unspecified fracture of sacrum, initial encounter for closed fracture
Unspecified fracture of sacrum, initial encounter for open fracture
Fracture of coccyx, initial encounter for closed fracture
Fracture of coccyx, initial encounter for open fracture
Concussion and edema of lumbar spinal cord, initial encounter
Concussion and edema of sacral spinal cord, initial encounter
Unspecified injury to L1 level of lumbar spinal cord, initial encounter
Unspecified injury to unspecified level of lumbar spinal cord, initial encounter
Complete lesion of L1 level of lumbar spinal cord, initial encounter
Complete lesion of unspecified level of lumbar spinal cord, initial encounter
Incomplete lesion of L1 level of lumbar spinal cord, initial encounter
Page 31
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S34.122A
S34.123A
S34.124A
S34.125A
S34.129A
S34.131A
S34.132A
S34.139A
S34.21XA
S34.22XA
S34.3XXA
S34.4XXA
S34.5XXA
S34.6XXA
S34.8XXA
S34.9XXA
S44.00XA
S44.01XA
S44.02XA
S44.10XA
S44.11XA
S44.12XA
S44.20XA
S44.21XA
S44.22XA
S44.30XA
S44.31XA
S44.32XA
S44.40XA
S44.41XA
S44.42XA
S44.50XA
S44.51XA
Description
Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter
Complete lesion of sacral spinal cord, initial encounter
Incomplete lesion of sacral spinal cord, initial encounter
Unspecified injury to sacral spinal cord, initial encounter
Injury of nerve root of lumbar spine, initial encounter
Injury of nerve root of sacral spine, initial encounter
Injury of cauda equina, initial encounter
Injury of lumbosacral plexus, initial encounter
Injury of lumbar, sacral and pelvic sympathetic nerves, initial encounter
Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, initial
encounter
Injury of other nerves at abdomen, lower back and pelvis level, initial encounter
Injury of unspecified nerves at abdomen, lower back and pelvis level, initial
encounter
Injury of ulnar nerve at upper arm level, unspecified arm, initial encounter
Injury of ulnar nerve at upper arm level, right arm, initial encounter
Injury of ulnar nerve at upper arm level, left arm, initial encounter
Injury of median nerve at upper arm level, unspecified arm, initial encounter
Injury of median nerve at upper arm level, right arm, initial encounter
Injury of median nerve at upper arm level, left arm, initial encounter
Injury of radial nerve at upper arm level, unspecified arm, initial encounter
Injury of radial nerve at upper arm level, right arm, initial encounter
Injury of radial nerve at upper arm level, left arm, initial encounter
Injury of axillary nerve, unspecified arm, initial encounter
Injury of axillary nerve, right arm, initial encounter
Injury of axillary nerve, left arm, initial encounter
Injury of musculocutaneous nerve, unspecified arm, initial encounter
Injury of musculocutaneous nerve, right arm, initial encounter
Injury of musculocutaneous nerve, left arm, initial encounter
Injury of cutaneous sensory nerve at shoulder and upper arm level, unspecified
arm, initial encounter
Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm,
initial encounter
Page 32
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S44.52XA
S44.8X1A
S44.8X2A
S44.8X9A
S44.90XA
S44.91XA
S44.92XA
S54.00XA
S54.01XA
S54.02XA
S54.10XA
S54.11XA
S54.12XA
S54.20XA
S54.21XA
S54.22XA
S54.30XA
S54.31XA
S54.32XA
S54.8X1A
S54.8X2A
S54.8X9A
S54.90XA
S54.91XA
S54.92XA
S64.00XA
S64.01XA
S64.02XA
Description
Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm,
initial encounter
Injury of other nerves at shoulder and upper arm level, right arm, initial
encounter
Injury of other nerves at shoulder and upper arm level, left arm, initial
encounter
Injury of other nerves at shoulder and upper arm level, unspecified arm, initial
encounter
Injury of unspecified nerve at shoulder and upper arm level, unspecified arm,
initial encounter
Injury of unspecified nerve at shoulder and upper arm level, right arm, initial
encounter
Injury of unspecified nerve at shoulder and upper arm level, left arm, initial
encounter
Injury of ulnar nerve at forearm level, unspecified arm, initial encounter
Injury of ulnar nerve at forearm level, right arm, initial encounter
Injury of ulnar nerve at forearm level, left arm, initial encounter
Injury of median nerve at forearm level, unspecified arm, initial encounter
Injury of median nerve at forearm level, right arm, initial encounter
Injury of median nerve at forearm level, left arm, initial encounter
Injury of radial nerve at forearm level, unspecified arm, initial encounter
Injury of radial nerve at forearm level, right arm, initial encounter
Injury of radial nerve at forearm level, left arm, initial encounter
Injury of cutaneous sensory nerve at forearm level, unspecified arm, initial
encounter
Injury of cutaneous sensory nerve at forearm level, right arm, initial encounter
Injury of cutaneous sensory nerve at forearm level, left arm, initial encounter
Unspecified injury of other nerves at forearm level, right arm, initial encounter
Unspecified injury of other nerves at forearm level, left arm, initial encounter
Unspecified injury of other nerves at forearm level, unspecified arm, initial
encounter
Injury of unspecified nerve at forearm level, unspecified arm, initial encounter
Injury of unspecified nerve at forearm level, right arm, initial encounter
Injury of unspecified nerve at forearm level, left arm, initial encounter
Injury of ulnar nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of ulnar nerve at wrist and hand level of right arm, initial encounter
Injury of ulnar nerve at wrist and hand level of left arm, initial encounter
Page 33
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S64.10XA
S64.11XA
S64.12XA
S64.20XA
S64.21XA
S64.22XA
S64.30XA
S64.31XA
S64.32XA
S64.40XA
S64.490A
S64.491A
S64.492A
S64.493A
S64.494A
S64.495A
S64.496A
S64.497A
S64.498A
S64.8X1A
S64.8X2A
S64.8X9A
S64.90XA
S64.91XA
S64.92XA
S74.00XA
S74.01XA
S74.02XA
S74.10XA
S74.11XA
S74.12XA
Description
Injury of median nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of median nerve at wrist and hand level of right arm, initial encounter
Injury of median nerve at wrist and hand level of left arm, initial encounter
Injury of radial nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of radial nerve at wrist and hand level of right arm, initial encounter
Injury of radial nerve at wrist and hand level of left arm, initial encounter
Injury of digital nerve of unspecified thumb, initial encounter
Injury of digital nerve of right thumb, initial encounter
Injury of digital nerve of left thumb, initial encounter
Injury of digital nerve of unspecified finger, initial encounter
Injury of digital nerve of right index finger, initial encounter
Injury of digital nerve of left index finger, initial encounter
Injury of digital nerve of right middle finger, initial encounter
Injury of digital nerve of left middle finger, initial encounter
Injury of digital nerve of right ring finger, initial encounter
Injury of digital nerve of left ring finger, initial encounter
Injury of digital nerve of right little finger, initial encounter
Injury of digital nerve of left little finger, initial encounter
Injury of digital nerve of other finger, initial encounter
Injury of other nerves at wrist and hand level of right arm, initial encounter
Injury of other nerves at wrist and hand level of left arm, initial encounter
Injury of other nerves at wrist and hand level of unspecified arm, initial
encounter
Injury of unspecified nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of unspecified nerve at wrist and hand level of right arm, initial
encounter
Injury of unspecified nerve at wrist and hand level of left arm, initial encounter
Injury of sciatic nerve at hip and thigh level, unspecified leg, initial encounter
Injury of sciatic nerve at hip and thigh level, right leg, initial encounter
Injury of sciatic nerve at hip and thigh level, left leg, initial encounter
Injury of femoral nerve at hip and thigh level, unspecified leg, initial encounter
Injury of femoral nerve at hip and thigh level, right leg, initial encounter
Injury of femoral nerve at hip and thigh level, left leg, initial encounter
Page 34
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S74.20XA
S74.21XA
S74.22XA
S74.8X1A
S74.8X2A
S74.8X9A
S74.90XA
S74.91XA
S74.92XA
S84.00XA
S84.01XA
S84.02XA
S84.10XA
S84.11XA
S84.12XA
S84.20XA
S84.21XA
S84.22XA
S84.801A
S84.802A
S84.809A
S84.90XA
S84.91XA
S84.92XA
S94.00XA
S94.01XA
S94.02XA
S94.10XA
S94.11XA
S94.12XA
S94.20XA
Description
Injury of cutaneous sensory nerve at hip and thigh level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at hip and high level, right leg, initial
encounter
Injury of cutaneous sensory nerve at hip and thigh level, left leg, initial
encounter
Injury of other nerves at hip and thigh level, right leg, initial encounter
Injury of other nerves at hip and thigh level, left leg, initial encounter
Injury of other nerves at hip and thigh level, unspecified leg, initial encounter
Injury of unspecified nerve at hip and thigh level, unspecified leg, initial
encounter
Injury of unspecified nerve at hip and thigh level, right leg, initial encounter
Injury of unspecified nerve at hip and thigh level, left leg, initial encounter
Injury of tibial nerve at lower leg level, unspecified leg, initial encounter
Injury of tibial nerve at lower leg level, right leg, initial encounter
Injury of tibial nerve at lower leg level, left leg, initial encounter
Injury of peroneal nerve at lower leg level, unspecified leg, initial encounter
Injury of peroneal nerve at lower leg level, right leg, initial encounter
Injury of peroneal nerve at lower leg level, left leg, initial encounter
Injury of cutaneous sensory nerve at lower leg level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at lower leg level, right leg, initial encounter
Injury of cutaneous sensory nerve at lower leg level, left leg, initial encounter
Injury of other nerves at lower leg level, right leg, initial encounter
Injury of other nerves at lower leg level, left leg, initial encounter
Injury of other nerves at lower leg level, unspecified leg, initial encounter
Injury of unspecified nerve at lower leg level, unspecified leg, initial encounter
Injury of unspecified nerve at lower leg level, right leg, initial encounter
Injury of unspecified nerve at lower leg level, left leg, initial encounter
Injury of lateral plantar nerve, unspecified leg, initial encounter
Injury of lateral plantar nerve, right leg, initial encounter
Injury of lateral plantar nerve, left leg, initial encounter
Injury of medial plantar nerve, unspecified leg, initial encounter
Injury of medial plantar nerve, right leg, initial encounter
Injury of medial plantar nerve, left leg, initial encounter
Injury of deep peroneal nerve at ankle and foot level, unspecified leg, initial
encounter
Page 35
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
S94.21XA
S94.22XA
S94.30XA
S94.31XA
S94.32XA
S94.8X1A
S94.8X2A
S94.8X9A
S94.90XA
S94.91XA
S94.92XA
A52.15
E08.40
E08.41
E08.42
E08.43
E08.44
E08.49
E08.610
E09.40
E09.41
E09.42
E09.43
E09.44
E09.49
Description
Injury of deep peroneal nerve at ankle and foot level, right leg, initial encounter
Injury of deep peroneal nerve at ankle and foot level, left leg, initial encounter
Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at ankle and foot level, right leg, initial
encounter
Injury of cutaneous sensory nerve at ankle and foot level, left leg, initial
encounter
Injury of other nerves at ankle and foot level, right leg, initial encounter
Injury of other nerves at ankle and foot level, left leg, initial encounter
Injury of other nerves at ankle and foot level, unspecified leg, initial encounter
Injury of unspecified nerve at ankle and foot level, unspecified leg, initial
encounter
Injury of unspecified nerve at ankle and foot level, right leg, initial encounter
Injury of unspecified nerve at ankle and foot level, left leg, initial encounter
Late syphilitic neuropathy
Diabetes mellitus due to underlying condition with diabetic neuropathy,
unspecified
Diabetes mellitus due to underlying condition with diabetic mononeuropathy
Diabetes mellitus due to underlying condition with diabetic polyneuropathy
Diabetes mellitus due to underlying condition with diabetic autonomic
(poly)neuropathy
Diabetes mellitus due to underlying condition with diabetic amyotrophy
Diabetes mellitus due to underlying condition with other diabetic neurological
complication
Diabetes mellitus due to underlying condition with diabetic neuropathic
arthropathy
with diabetic neuropathy, unspecified
with diabetic mononeuropathy
with diabetic polyneuropathy
with diabetic autonomic (poly)neuropathy
with diabetic amyotrophy
with other diabetic neurological complication
Page 36
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
E09.610
Drug or chemical induced diabetes mellitus with diabetic neuropathic
arthropathy
Other specified diabetes mellitus with diabetic neuropathy, unspecified
Other specified diabetes mellitus with diabetic mononeuropathy
Other specified diabetes mellitus with diabetic polyneuropathy
Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy
Other specified diabetes mellitus with diabetic amyotrophy
Other specified diabetes mellitus with other diabetic neurological complication
Other specified diabetes mellitus with diabetic neuropathic arthropathy
Motor neuron disease, unspecified
Amyotrophic lateral sclerosis
Progressive bulbar palsy
Other motor neuron disease
Other spinal muscular atrophies and related syndromes
Paraneoplastic neuromyopathy and neuropathy
Other systemic atrophy primarily affecting central nervous system in neoplastic
disease
Brachial plexus disorders
Lumbosacral plexus disorders
Cervical root disorders, not elsewhere classified
Thoracic root disorders, not elsewhere classified
Lumbosacral root disorders, not elsewhere classified
Other nerve root and plexus disorders
Nerve root and plexus disorder, unspecified
Nerve root and plexus compressions in diseases classified elsewhere
Carpal tunnel syndrome, unspecified upper limb
E10.40
E10.41
E10.42
E10.43
E10.44
E10.49
E10.610
E11.40
E11.41
E11.42
E11.43
E11.44
E11.49
E11.610
E13.40
E13.41
E13.42
E13.43
E13.44
E13.49
E13.610
G12.20
G12.21
G12.22
G12.29
G12.8
G13.0
G13.1
G54.0
G54.1
G54.2
G54.3
G54.4
G54.8
G54.9
G55
G56.00
Page 37
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
G56.01
G56.02
G56.10
G56.11
G56.12
G56.20
G56.21
G56.22
G56.30
G56.31
G56.32
G56.40
G56.41
G56.42
G56.80
G56.81
G56.82
G56.90
G56.91
G56.92
G57.00
G57.01
G57.02
G57.10
G57.11
G57.12
G57.20
G57.21
G57.22
G57.30
G57.31
G57.32
G57.40
G57.41
G57.42
G57.50
G57.51
G57.52
G57.60
G57.61
Carpal tunnel syndrome, right upper limb
Carpal tunnel syndrome, left upper limb
Other lesions of median nerve, unspecified upper limb
Other lesions of median nerve, right upper limb
Other lesions of median nerve, left upper limb
Lesion of ulnar nerve, unspecified upper limb
Lesion of ulnar nerve, right upper limb
Lesion of ulnar nerve, left upper limb
Lesion of radial nerve, unspecified upper limb
Lesion of radial nerve, right upper limb
Lesion of radial nerve, left upper limb
Causalgia of unspecified upper limb
Causalgia of right upper limb
Causalgia of left upper limb
Other specified mononeuropathies of unspecified upper limb
Other specified mononeuropathies of right upper limb
Other specified mononeuropathies of left upper limb
Unspecified mononeuropathy of unspecified upper limb
Unspecified mononeuropathy of right upper limb
Unspecified mononeuropathy of left upper limb
Lesion of sciatic nerve, unspecified lower limb
Lesion of sciatic nerve, right lower limb
Lesion of sciatic nerve, left lower limb
Meralgia paresthetica, unspecified lower limb
Meralgia paresthetica, right lower limb
Meralgia paresthetica, left lower limb
Lesion of femoral nerve, unspecified lower limb
Lesion of femoral nerve, right lower limb
Lesion of femoral nerve, left lower limb
Lesion of lateral popliteal nerve, unspecified lower limb
Lesion of lateral popliteal nerve, right lower limb
Lesion of lateral popliteal nerve, left lower limb
Lesion of medial popliteal nerve, unspecified lower limb
Lesion of medial popliteal nerve, right lower limb
Lesion of medial popliteal nerve, left lower limb
Tarsal tunnel syndrome, unspecified lower limb
Tarsal tunnel syndrome, right lower limb
Tarsal tunnel syndrome, left lower limb
Lesion of plantar nerve, unspecified lower limb
Lesion of plantar nerve, right lower limb
Page 38
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
G57.62
G57.70
G57.71
G57.72
G57.80
G57.81
G57.82
G57.90
G57.91
G57.92
G58.0
G58.7
G58.9
G59
G60.0
G60.1
G60.2
G60.3
G60.8
G60.9
G61.0
G61.1
G61.81
G61.89
G61.9
G62.0
G62.1
G62.2
G62.81
G62.82
G62.89
G62.9
G63
G64
G70.00
G70.01
G70.1
G70.2
G70.80
G70.81
Lesion of plantar nerve, left lower limb
Causalgia of unspecified lower limb
Causalgia of right lower limb
Causalgia of left lower limb
Other specified mononeuropathies of unspecified lower limb
Other specified mononeuropathies of right lower limb
Other specified mononeuropathies of left lower limb
Unspecified mononeuropathy of unspecified lower limb
Unspecified mononeuropathy of right lower limb
Unspecified mononeuropathy of left lower limb
Intercostal neuropathy
Mononeuritis multiplex
Mononeuropathy, unspecified
Mononeuropathy in diseases classified elsewhere
Hereditary motor and sensory neuropathy
Refsum's disease
Neuropathy in association with hereditary ataxia
Idiopathic progressive neuropathy
Other hereditary and idiopathic neuropathies
Hereditary and idiopathic neuropathy, unspecified
Guillain-Barre syndrome
Serum neuropathy
Chronic inflammatory demyelinating polyneuritis
Other inflammatory polyneuropathies
Inflammatory polyneuropathy, unspecified
Drug-induced polyneuropathy
Alcoholic polyneuropathy
Polyneuropathy due to other toxic agents
Critical illness polyneuropathy
Radiation-induced polyneuropathy
Other specified polyneuropathies
Polyneuropathy, unspecified
Polyneuropathy in diseases classified elsewhere
Other disorders of peripheral nervous system
Myasthenia gravis without (acute) exacerbation
Myasthenia gravis with (acute) exacerbation
Toxic myoneural disorders
Congenital and developmental myasthenia
Lambert-Eaton syndrome, unspecified
Lambert-Eaton syndrome in disease classified elsewhere
Page 39
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
G70.89
G70.9
G71.0
G71.11
G71.12
G71.13
G71.14
G71.19
G71.2
G71.3
G72.0
G72.1
G72.2
G72.3
G72.41
G72.49
G72.81
G72.89
G72.9
G73.1
G73.3
G73.7
G90.01
G90.09
G90.2
G90.4
G90.50
G90.511
G90.512
G90.513
G90.519
G90.521
G90.522
G90.523
G90.529
G90.59
G90.8
G90.9
G99.0
M05.40
Other specified myoneural disorders
Myoneural disorder, unspecified
Muscular dystrophy
Myotonic muscular dystrophy
Myotonia congenita
Myotonic chondrodystrophy
Drug induced myotonia
Other specified myotonic disorders
Congenital myopathies
Mitochondrial myopathy, not elsewhere classified
Drug-induced myopathy
Alcoholic myopathy
Myopathy due to other toxic agents
Periodic paralysis
Inclusion body myositis [IBM]
Other inflammatory and immune myopathies, not elsewhere classified
Critical illness myopathy
Other specified myopathies
Myopathy, unspecified
Lambert-Eaton syndrome in neoplastic disease
Myasthenic syndromes in other diseases classified elsewhere
Myopathy in diseases classified elsewhere
Carotid sinus syncope
Other idiopathic peripheral autonomic neuropathy
Horner's syndrome
Autonomic dysreflexia
Complex regional pain syndrome I, unspecified
Complex regional pain syndrome I of right upper limb
Complex regional pain syndrome I of left upper limb
Complex regional pain syndrome I of upper limb, bilateral
Complex regional pain syndrome I of unspecified upper limb
Complex regional pain syndrome I of right lower limb
Complex regional pain syndrome I of left lower limb
Complex regional pain syndrome I of lower limb, bilateral
Complex regional pain syndrome I of unspecified lower limb
Complex regional pain syndrome I of other specified site
Other disorders of autonomic nervous system
Disorder of the autonomic nervous system, unspecified
Autonomic neuropathy in diseases classified elsewhere
Rheumatoid myopathy with rheumatoid arthritis of unspecified site
Page 40
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
M05.411
M05.412
M05.419
M05.421
M05.422
M05.429
M05.431
M05.432
M05.439
M05.441
M05.442
M05.449
M05.451
M05.452
M05.459
M05.461
M05.462
M05.469
M05.471
M05.472
M05.479
M05.49
M05.50
M05.511
M05.512
M05.519
M05.521
M05.522
M05.529
M05.531
M05.532
M05.539
M05.541
M05.542
M05.549
M05.551
M05.552
M05.559
M05.561
M05.562
Rheumatoid myopathy with rheumatoid arthritis of right shoulder
Rheumatoid myopathy with rheumatoid arthritis of left shoulder
Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder
Rheumatoid myopathy with rheumatoid arthritis of right elbow
Rheumatoid myopathy with rheumatoid arthritis of left elbow
Rheumatoid myopathy with rheumatoid arthritis of unspecified elbow
Rheumatoid myopathy with rheumatoid arthritis of right wrist
Rheumatoid myopathy with rheumatoid arthritis of left wrist
Rheumatoid myopathy with rheumatoid arthritis of unspecified wrist
Rheumatoid myopathy with rheumatoid arthritis of right hand
Rheumatoid myopathy with rheumatoid arthritis of left hand
Rheumatoid myopathy with rheumatoid arthritis of unspecified hand
Rheumatoid myopathy with rheumatoid arthritis of right hip
Rheumatoid myopathy with rheumatoid arthritis of left hip
Rheumatoid myopathy with rheumatoid arthritis of unspecified hip
Rheumatoid myopathy with rheumatoid arthritis of right knee
Rheumatoid myopathy with rheumatoid arthritis of left knee
Rheumatoid myopathy with rheumatoid arthritis of unspecified knee
Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot
Rheumatoid myopathy with rheumatoid arthritis of multiple sites
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified site
Rheumatoid polyneuropathy with rheumatoid arthritis of right shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of left shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified shoulder
Rheumatoid polyneuropathy with rheumatoid arthritis of right elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of left elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified elbow
Rheumatoid polyneuropathy with rheumatoid arthritis of right wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of left wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified wrist
Rheumatoid polyneuropathy with rheumatoid arthritis of right hand
Rheumatoid polyneuropathy with rheumatoid arthritis of left hand
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hand
Rheumatoid polyneuropathy with rheumatoid arthritis of right hip
Rheumatoid polyneuropathy with rheumatoid arthritis of left hip
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified hip
Rheumatoid polyneuropathy with rheumatoid arthritis of right knee
Rheumatoid polyneuropathy with rheumatoid arthritis of left knee
Page 41
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
M05.569
M05.571
M05.572
M05.579
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee
Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and
foot
Rheumatoid polyneuropathy with rheumatoid arthritis of multiple sites
Juvenile dermatopolymyositis, organ involvement unspecified
Juvenile dermatopolymyositis with respiratory involvement
Juvenile dermatopolymyositis with myopathy
Juvenile dermatopolymyositis with other organ involvement
Other dermatopolymyositis, organ involvement unspecified
Other dermatopolymyositis with respiratory involvement
Other dermatopolymyositis with myopathy
Other dermatopolymyositis with other organ involvement
Polymyositis, organ involvement unspecified
Polymyositis with respiratory involvement
Polymyositis with other organ involvement
Dermatopolymyositis, unspecified, organ involvement unspecified
Dermatopolymyositis, unspecified with respiratory involvement
Dermatopolymyositis, unspecified with myopathy
Dermatopolymyositis, unspecified with other organ involvement
Systemic sclerosis with myopathy
Systemic sclerosis with polyneuropathy
Sicca syndrome with myopathy
Dermato(poly)myositis in neoplastic disease
Intervertebral disc disorders with radiculopathy, thoracic region
Intervertebral disc disorders with radiculopathy, thoracolumbar region
Intervertebral disc disorders with radiculopathy, lumbar region
Intervertebral disc disorders with radiculopathy, lumbosacral region
Radiculopathy, occipito-atlanto-axial region
Radiculopathy, cervical region
Radiculopathy, cervicothoracic region
Radiculopathy, thoracic region
Radiculopathy, thoracolumbar region
Radiculopathy, lumbar region
Radiculopathy, lumbosacral region
Injury of oculomotor nerve, unspecified side, initial encounter
Injury of oculomotor nerve, right side, initial encounter
M05.59
M33.00
M33.01
M33.02
M33.09
M33.10
M33.11
M33.12
M33.19
M33.20
M33.21
M33.22
M33.22
M33.29
M33.90
M33.91
M33.92
M33.99
M34.82
M34.83
M35.03
M36.0
M51.14
M51.15
M51.16
M51.17
M54.11
M54.12
M54.13
M54.14
M54.15
M54.16
M54.17
S04.10XA
S04.11XA
Page 42
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S04.12XA
S04.20XA
S04.21XA
S04.22XA
S04.30XA
S04.31XA
S04.32XA
S04.40XA
S04.41XA
S04.42XA
S04.50XA
S04.51XA
S04.52XA
S04.60XA
S04.61XA
S04.62XA
S04.70XA
S04.71XA
S04.72XA
S04.811A
S04.812A
S04.819A
S04.891A
S04.892A
S04.899A
S04.9XXA
S12.000A
Injury of oculomotor nerve, left side, initial encounter
Injury of trochlear nerve, unspecified side, initial encounter
Injury of trochlear nerve, right side, initial encounter
Injury of trochlear nerve, left side, initial encounter
Injury of trigeminal nerve, unspecified side, initial encounter
Injury of trigeminal nerve, right side, initial encounter
Injury of trigeminal nerve, left side, initial encounter
Injury of abducent nerve, unspecified side, initial encounter
Injury of abducent nerve, right side, initial encounter
Injury of abducent nerve, left side, initial encounter
Injury of facial nerve, unspecified side, initial encounter
Injury of facial nerve, right side, initial encounter
Injury of facial nerve, left side, initial encounter
Injury of acoustic nerve, unspecified side, initial encounter
Injury of acoustic nerve, right side, initial encounter
Injury of acoustic nerve, left side, initial encounter
Injury of accessory nerve, unspecified side, initial encounter
Injury of accessory nerve, right side, initial encounter
Injury of accessory nerve, left side, initial encounter
Injury of olfactory [1st ] nerve, right side, initial encounter
Injury of olfactory [1st ] nerve, left side, initial encounter
Injury of olfactory [1st ] nerve, unspecified side, initial encounter
Injury of other cranial nerves, right side, initial encounter
Injury of other cranial nerves, left side, initial encounter
Injury of other cranial nerves, unspecified side, initial encounter
Injury of unspecified cranial nerve, initial encounter
closed fracture
open fracture
closed fracture
open fracture
closed fracture
open fracture
for closed fracture
S12.000B
S12.001A
S12.001B
S12.100A
S12.100B
S12.101A
Page 43
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S12.101B
for open fracture
closed fracture
open fracture
for closed fracture
for open fracture
closed fracture
open fracture
for closed fracture
for open fracture
closed fracture
open fracture
closed fracture
open fracture
closed fracture
open fracture
for closed fracture
for open fracture
closed fracture
open fracture
for closed fracture
S12.200A
S12.200B
S12.201A
S12.201B
S12.300A
S12.300B
S12.301A
S12.301B
S12.400A
S12.400B
S12.401A
S12.401B
S12.500A
S12.500B
S12.501A
S12.501B
S12.600A
S12.600B
S12.601A
Page 44
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S12.601B
for open fracture
Fracture of neck, unspecified, initial encounter
Concussion and edema of cervical spinal cord, initial encounter
Unspecified injury at unspecified level of cervical spinal cord, initial encounter
Complete lesion at unspecified level of cervical spinal cord, initial encounter
Central cord syndrome at unspecified level of cervical spinal cord, initial
encounter
S12.9XXA
S14.0XXA
S14.101A
S14.102A
S14.103A
S14.104A
S14.105A
S14.106A
S14.107A
S14.108A
S14.109A
S14.111A
S14.112A
S14.113A
S14.114A
S14.115A
S14.116A
S14.117A
S14.118A
S14.119A
S14.121A
S14.122A
S14.123A
S14.124A
S14.125A
S14.126A
S14.127A
S14.128A
S14.129A
S14.131A
S14.132A
S14.133A
S14.134A
S14.135A
S14.136A
S14.137A
S14.138A
Page 45
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S14.139A
Anterior cord syndrome at unspecified level of cervical spinal cord, initial
encounter
Brown-Sequard syndrome at unspecified level of cervical spinal cord, initial
encounter
encounter
Injury of nerve root of cervical spine, initial encounter
Injury of peripheral nerves of neck, initial encounter
Injury of cervical sympathetic nerves, initial encounter
Injury of other specified nerves of neck, initial encounter
Injury of unspecified nerves of neck, initial encounter
Unspecified fracture of unspecified thoracic vertebra, initial encounter for
closed fracture
Unspecified fracture of unspecified thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of first thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of first thoracic vertebra, initial encounter for open fracture
Unspecified fracture of second thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of second thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of third thoracic vertebra, initial encounter for closed
fracture
S14.141A
S14.142A
S14.143A
S14.144A
S14.145A
S14.146A
S14.147A
S14.148A
S14.149A
S14.151A
S14.152A
S14.153A
S14.154A
S14.155A
S14.156A
S14.157A
S14.158A
S14.159A
S14.2XXA
S14.4XXA
S14.5XXA
S14.8XXA
S14.9XXA
S22.009A
S22.009B
S22.019A
S22.019B
S22.029A
S22.029B
S22.039A
Page 46
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S22.039B
Unspecified fracture of third thoracic vertebra, initial encounter for open
fracture
Unspecified fracture of fourth thoracic vertebra, initial encounter for closed
fracture
Unspecified fracture of fourth thoracic vertebra, initial encounter for open
fracture
Concussion and edema of thoracic spinal cord, initial encounter
Unspecified injury at T1 level of thoracic spinal cord, initial encounter
Unspecified injury at unspecified level of thoracic spinal cord, initial encounter
Unspecified injury at unspecified level of thoracic spinal cord, subsequent
encounter
Unspecified injury at unspecified level of thoracic spinal cord, sequela
Complete lesion at T1 level of thoracic spinal cord, initial encounter
Complete lesion at unspecified level of thoracic spinal cord, initial encounter
Anterior cord syndrome at T1 level of thoracic spinal cord, initial encounter
Anterior cord syndrome at T2-T6 level of thoracic spinal cord, initial encounter
encounter
encounter
Anterior cord syndrome at unspecified level of thoracic spinal cord, initial
encounter
Brown-Sequard syndrome at T1 level of thoracic spinal cord, initial encounter
encounter
S22.049A
S22.049B
S22.059A
S22.059B
S22.069A
S22.069B
S22.079A
S22.079B
S22.089A
S22.089B
S24.0XXA
S24.101A
S24.102A
S24.103A
S24.104A
S24.109A
S24.109D
S24.109S
S24.111A
S24.112A
S24.113A
S24.114A
S24.119A
S24.131A
S24.132A
S24.133A
S24.134A
S24.139A
S24.141A
S24.142A
Page 47
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S24.143A
encounter
encounter
Brown-Sequard syndrome at unspecified level of thoracic spinal cord, initial
encounter
Other incomplete lesion at T1 level of thoracic spinal cord, initial encounter
Other incomplete lesion at T2-T6 level of thoracic spinal cord, initial encounter
encounter
encounter
encounter
Injury of nerve root of thoracic spine, initial encounter
Injury of peripheral nerves of thorax, initial encounter
Injury of thoracic sympathetic nervous system, initial encounter
Injury of other specified nerves of thorax, initial encounter
Injury of unspecified nerve of thorax, initial encounter
Unspecified fracture of unspecified lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of unspecified lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of first lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of first lumbar vertebra, initial encounter for open fracture
Unspecified fracture of second lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of second lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of third lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of third lumbar vertebra, initial encounter for open fracture
Unspecified fracture of fourth lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of fourth lumbar vertebra, initial encounter for open
fracture
Unspecified fracture of fifth lumbar vertebra, initial encounter for closed
fracture
Unspecified fracture of fifth lumbar vertebra, initial encounter for open fracture
Unspecified fracture of sacrum, initial encounter for closed fracture
S24.144A
S24.149A
S24.151A
S24.152A
S24.153A
S24.154A
S24.159A
S24.2XXA
S24.3XXA
S24.4XXA
S24.8XXA
S24.9XXA
S32.009A
S32.009B
S32.019A
S32.019B
S32.029A
S32.029B
S32.039A
S32.039B
S32.049A
S32.049B
S32.059A
S32.059B
S32.10XA
Page 48
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S32.10XB
S32.2XXA
S32.2XXB
S34.01XA
S34.02XA
S34.101A
S34.102A
S34.103A
S34.104A
S34.105A
S34.109A
S34.111A
S34.112A
S34.113A
S34.114A
S34.115A
S34.119A
S34.121A
S34.122A
S34.123A
S34.124A
S34.125A
S34.129A
S34.131A
S34.132A
S34.139A
S34.21XA
S34.22XA
S34.3XXA
S34.4XXA
S34.5XXA
S34.6XXA
Unspecified fracture of sacrum, initial encounter for open fracture
Fracture of coccyx, initial encounter for closed fracture
Fracture of coccyx, initial encounter for open fracture
Concussion and edema of lumbar spinal cord, initial encounter
Concussion and edema of sacral spinal cord, initial encounter
Unspecified injury to unspecified level of lumbar spinal cord, initial encounter
Complete lesion of unspecified level of lumbar spinal cord, initial encounter
Incomplete lesion of unspecified level of lumbar spinal cord, initial encounter
Complete lesion of sacral spinal cord, initial encounter
Incomplete lesion of sacral spinal cord, initial encounter
Unspecified injury to sacral spinal cord, initial encounter
Injury of nerve root of lumbar spine, initial encounter
Injury of nerve root of sacral spine, initial encounter
Injury of cauda equina, initial encounter
Injury of lumbosacral plexus, initial encounter
Injury of lumbar, sacral and pelvic sympathetic nerves, initial encounter
Injury of peripheral nerve(s) at abdomen, lower back and pelvis level, initial
encounter
Injury of other nerves at abdomen, lower back and pelvis level, initial encounter
Injury of unspecified nerves at abdomen, lower back and pelvis level, initial
encounter
Injury of ulnar nerve at upper arm level, unspecified arm, initial encounter
Injury of ulnar nerve at upper arm level, right arm, initial encounter
Injury of ulnar nerve at upper arm level, left arm, initial encounter
Injury of median nerve at upper arm level, unspecified arm, initial encounter
S34.8XXA
S34.9XXA
S44.00XA
S44.01XA
S44.02XA
S44.10XA
Page 49
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S44.11XA
S44.12XA
S44.20XA
S44.21XA
S44.22XA
S44.30XA
S44.31XA
S44.32XA
S44.40XA
S44.41XA
S44.42XA
S44.50XA
Injury of median nerve at upper arm level, right arm, initial encounter
Injury of median nerve at upper arm level, left arm, initial encounter
Injury of radial nerve at upper arm level, unspecified arm, initial encounter
Injury of radial nerve at upper arm level, right arm, initial encounter
Injury of radial nerve at upper arm level, left arm, initial encounter
Injury of axillary nerve, unspecified arm, initial encounter
Injury of axillary nerve, right arm, initial encounter
Injury of axillary nerve, left arm, initial encounter
Injury of musculocutaneous nerve, unspecified arm, initial encounter
Injury of musculocutaneous nerve, right arm, initial encounter
Injury of musculocutaneous nerve, left arm, initial encounter
Injury of cutaneous sensory nerve at shoulder and upper arm level, unspecified
arm, initial encounter
Injury of cutaneous sensory nerve at shoulder and upper arm level, right arm,
initial encounter
Injury of cutaneous sensory nerve at shoulder and upper arm level, left arm,
initial encounter
Injury of other nerves at shoulder and upper arm level, right arm, initial
encounter
Injury of other nerves at shoulder and upper arm level, left arm, initial
encounter
Injury of other nerves at shoulder and upper arm level, unspecified arm, initial
encounter
Injury of unspecified nerve at shoulder and upper arm level, unspecified arm,
initial encounter
Injury of unspecified nerve at shoulder and upper arm level, right arm, initial
encounter
Injury of unspecified nerve at shoulder and upper arm level, left arm, initial
encounter
Injury of ulnar nerve at forearm level, unspecified arm, initial encounter
Injury of ulnar nerve at forearm level, right arm, initial encounter
Injury of ulnar nerve at forearm level, left arm, initial encounter
Injury of median nerve at forearm level, unspecified arm, initial encounter
Injury of median nerve at forearm level, right arm, initial encounter
Injury of median nerve at forearm level, left arm, initial encounter
Injury of radial nerve at forearm level, unspecified arm, initial encounter
Injury of radial nerve at forearm level, right arm, initial encounter
Injury of radial nerve at forearm level, left arm, initial encounter
Injury of cutaneous sensory nerve at forearm level, unspecified arm, initial
encounter
S44.51XA
S44.52XA
S44.8X1A
S44.8X2A
S44.8X9A
S44.90XA
S44.91XA
S44.92XA
S54.00XA
S54.01XA
S54.02XA
S54.10XA
S54.11XA
S54.12XA
S54.20XA
S54.21XA
S54.22XA
S54.30XA
Page 50
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S54.31XA
S54.32XA
S54.8X1A
S54.8X2A
S54.8X9A
Injury of cutaneous sensory nerve at forearm level, right arm, initial encounter
Injury of cutaneous sensory nerve at forearm level, left arm, initial encounter
Unspecified injury of other nerves at forearm level, right arm, initial encounter
Unspecified injury of other nerves at forearm level, left arm, initial encounter
Unspecified injury of other nerves at forearm level, unspecified arm, initial
encounter
Injury of unspecified nerve at forearm level, unspecified arm, initial encounter
Injury of unspecified nerve at forearm level, right arm, initial encounter
Injury of unspecified nerve at forearm level, left arm, initial encounter
Injury of ulnar nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of ulnar nerve at wrist and hand level of right arm, initial encounter
Injury of ulnar nerve at wrist and hand level of left arm, initial encounter
Injury of median nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of median nerve at wrist and hand level of right arm, initial encounter
Injury of median nerve at wrist and hand level of left arm, initial encounter
Injury of radial nerve at wrist and hand level of unspecified arm, initial
encounter
Injury of radial nerve at wrist and hand level of right arm, initial encounter
Injury of radial nerve at wrist and hand level of left arm, initial encounter
Injury of digital nerve of unspecified thumb, initial encounter
Injury of digital nerve of right thumb, initial encounter
Injury of digital nerve of left thumb, initial encounter
Injury of digital nerve of unspecified finger, initial encounter
Injury of digital nerve of right index finger, initial encounter
Injury of digital nerve of left index finger, initial encounter
Injury of digital nerve of right middle finger, initial encounter
Injury of digital nerve of left middle finger, initial encounter
Injury of digital nerve of right ring finger, initial encounter
Injury of digital nerve of left ring finger, initial encounter
Injury of digital nerve of right little finger, initial encounter
Injury of digital nerve of left little finger, initial encounter
Injury of digital nerve of other finger, initial encounter
Injury of other nerves at wrist and hand level of right arm, initial encounter
Injury of other nerves at wrist and hand level of left arm, initial encounter
Injury of other nerves at wrist and hand level of unspecified arm, initial
encounter
Injury of unspecified nerve at wrist and hand level of unspecified arm, initial
encounter
S54.90XA
S54.91XA
S54.92XA
S64.00XA
S64.01XA
S64.02XA
S64.10XA
S64.11XA
S64.12XA
S64.20XA
S64.21XA
S64.22XA
S64.30XA
S64.31XA
S64.32XA
S64.40XA
S64.490A
S64.491A
S64.492A
S64.493A
S64.494A
S64.495A
S64.496A
S64.497A
S64.498A
S64.8X1A
S64.8X2A
S64.8X9A
S64.90XA
Page 51
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S64.91XA
Injury of unspecified nerve at wrist and hand level of right arm, initial
encounter
Injury of unspecified nerve at wrist and hand level of left arm, initial encounter
Injury of sciatic nerve at hip and thigh level, unspecified leg, initial encounter
Injury of sciatic nerve at hip and thigh level, right leg, initial encounter
Injury of sciatic nerve at hip and thigh level, left leg, initial encounter
Injury of femoral nerve at hip and thigh level, unspecified leg, initial encounter
Injury of femoral nerve at hip and thigh level, right leg, initial encounter
Injury of femoral nerve at hip and thigh level, left leg, initial encounter
Injury of cutaneous sensory nerve at hip and thigh level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at hip and high level, right leg, initial
encounter
Injury of cutaneous sensory nerve at hip and thigh level, left leg, initial
encounter
Injury of other nerves at hip and thigh level, right leg, initial encounter
Injury of other nerves at hip and thigh level, left leg, initial encounter
Injury of other nerves at hip and thigh level, unspecified leg, initial encounter
Injury of unspecified nerve at hip and thigh level, unspecified leg, initial
encounter
Injury of unspecified nerve at hip and thigh level, right leg, initial encounter
Injury of unspecified nerve at hip and thigh level, left leg, initial encounter
Injury of tibial nerve at lower leg level, unspecified leg, initial encounter
Injury of tibial nerve at lower leg level, right leg, initial encounter
Injury of tibial nerve at lower leg level, left leg, initial encounter
Injury of peroneal nerve at lower leg level, unspecified leg, initial encounter
Injury of peroneal nerve at lower leg level, right leg, initial encounter
Injury of peroneal nerve at lower leg level, left leg, initial encounter
Injury of cutaneous sensory nerve at lower leg level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at lower leg level, right leg, initial encounter
Injury of cutaneous sensory nerve at lower leg level, left leg, initial encounter
Injury of other nerves at lower leg level, right leg, initial encounter
Injury of other nerves at lower leg level, left leg, initial encounter
Injury of other nerves at lower leg level, unspecified leg, initial encounter
Injury of unspecified nerve at lower leg level, unspecified leg, initial encounter
Injury of unspecified nerve at lower leg level, right leg, initial encounter
Injury of unspecified nerve at lower leg level, left leg, initial encounter
Injury of lateral plantar nerve, unspecified leg, initial encounter
Injury of lateral plantar nerve, right leg, initial encounter
S64.92XA
S74.00XA
S74.01XA
S74.02XA
S74.10XA
S74.11XA
S74.12XA
S74.20XA
S74.21XA
S74.22XA
S74.8X1A
S74.8X2A
S74.8X9A
S74.90XA
S74.91XA
S74.92XA
S84.00XA
S84.01XA
S84.02XA
S84.10XA
S84.11XA
S84.12XA
S84.20XA
S84.21XA
S84.22XA
S84.801A
S84.802A
S84.809A
S84.90XA
S84.91XA
S84.92XA
S94.00XA
S94.01XA
Page 52
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
ICD-10-CM
Diagnosis Code*
Description
S94.02XA
S94.10XA
S94.11XA
S94.12XA
S94.20XA
Injury of lateral plantar nerve, left leg, initial encounter
Injury of medial plantar nerve, unspecified leg, initial encounter
Injury of medial plantar nerve, right leg, initial encounter
Injury of medial plantar nerve, left leg, initial encounter
Injury of deep peroneal nerve at ankle and foot level, unspecified leg, initial
encounter
Injury of deep peroneal nerve at ankle and foot level, right leg, initial encounter
Injury of deep peroneal nerve at ankle and foot level, left leg, initial encounter
Injury of cutaneous sensory nerve at ankle and foot level, unspecified leg, initial
encounter
Injury of cutaneous sensory nerve at ankle and foot level, right leg, initial
encounter
Injury of cutaneous sensory nerve at ankle and foot level, left leg, initial
encounter
Injury of other nerves at ankle and foot level, right leg, initial encounter
Injury of other nerves at ankle and foot level, left leg, initial encounter
Injury of other nerves at ankle and foot level, unspecified leg, initial encounter
Injury of unspecified nerve at ankle and foot level, unspecified leg, initial
encounter
Injury of unspecified nerve at ankle and foot level, right leg, initial encounter
Injury of unspecified nerve at ankle and foot level, left leg, initial encounter
S94.21XA
S94.22XA
S94.30XA
S94.31XA
S94.32XA
S94.8X1A
S94.8X2A
S94.8X9A
S94.90XA
S94.91XA
S94.92XA
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
IX. REFERENCES
Top
1. Gooch CL, Weimer LH. The electrodiagnosis of neuropathy: basic principles and
common pitfalls. Neurol Clin. Feb 2007;25(1):1-28. PMID 17324718
2. American Association of Electrodiagnostic M. Guidelines in electrodiagnostic medicine.
Recommended policy for electrodiagnostic medicine. Muscle Nerve Suppl. 1999;8:S91105. PMID 16921629
3. Lee DH, Claussen GC, Oh S. Clinical nerve conduction and needle electromyography
studies. J Am Acad Orthop Surg. Jul-Aug 2004;12(4):276-287. PMID 15473679
4. Ball N, Scurr J. Electromyography normalization methods for high-velocity muscle
actions: review and recommendations. J Appl Biomech. Oct 2013;29(5):600-608. PMID
23270917
Page 53
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
5. Blumenthal TD, Cuthbert BN, Filion DL, et al. Committee report: Guidelines for human
startle eyeblink electromyographic studies. Psychophysiology. Jan 2005;42(1):1-15.
PMID 15720576
6. Bolgla LA, Uhl TL. Reliability of electromyographic normalization methods for evaluating
the hip musculature. J Electromyogr Kinesiol. Feb 2007;17(1):102-111. PMID 16423539
7. Lariviere C, Gagnon D, Gravel D, et al. The assessment of back muscle capacity using
intermittent static contractions. Part I - Validity and reliability of electromyographic
indices of fatigue. J Electromyogr Kinesiol. Dec 2008;18(6):1006-1019. PMID 17643316
8. Lariviere C, Gravel D, Gagnon D, et al. The assessment of back muscle capacity using
intermittent static contractions. Part II: validity and reliability of biomechanical
correlates of muscle fatigue. J Electromyogr Kinesiol. Dec 2008;18(6):1020-1031. PMID
17643315
9. American Academy of Orthopaedic Surgeons (AAOS). Clinical Practice Guideline on the
Diagnosis of Carpal Tunnel Syndrome. 2004;
http://www.aaos.org/research/guidelines/CTS_guideline.pdf. Accessed November 23,
2015.
10. Fowler JR, Munsch M, Tosti R, et al. Comparison of ultrasound and electrodiagnostic
testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as
the reference standard. J Bone Joint Surg Am. Sep 3 2014;96(17):e148. PMID 25187592
11. Chang MH, Liu LH, Lee YC, et al. Comparison of sensitivity of transcarpal median motor
conduction velocity and conventional conduction techniques in electrodiagnosis of carpal
tunnel syndrome. Clin Neurophysiol. May 2006;117(5):984-991. PMID 16551510
12. Homan MM, Franzblau A, Werner RA, et al. Agreement between symptom surveys,
physical examination procedures and electrodiagnostic findings for the carpal tunnel
syndrome. Scand J Work Environ Health. Apr 1999;25(2):115-124. PMID 10360466
13. North American Spine Society (NASS) Evidence-Based Clinical Guidelines Committee.
Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. 2012;
https://www.spine.org/Documents/ResearchClinicalCare/Guidelines/LumbarDiscHerniati
on.pdf. Accessed November 23, 2015.
14. Mondelli M, Aretini A, Arrigucci U, et al. Clinical findings and electrodiagnostic testing
in 108 consecutive cases of lumbosacral radiculopathy due to herniated disc.
Neurophysiol Clin. Oct 2013;43(4):205-215. PMID 24094906
15. Marciniak C, Armon C, Wilson J, et al. Practice parameter: utility of electrodiagnostic
techniques in evaluating patients with suspected peroneal neuropathy: an evidence-based
review. Muscle Nerve. Apr 2005;31(4):520-527. PMID 15768387
16. Rabie M, Jossiphov J, Nevo Y. Electromyography (EMG) accuracy compared to muscle
biopsy in childhood. J Child Neurol. Jul 2007;22(7):803-808. PMID 17715269
17. American Academy of Orthopaedic Surgeons. Clinical guidelines: diagnosis of carpel
tunnel syndrome. 2007; http://www.aaos.org/research/guidelines/CTS_summary.pdf.
Accessed November 23, 2015.
Page 54
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
18. American Academy of Neurology (AAN). Position Statement: diagnostic
electromyography in the practice of medicine. 2004;
https://www.aanem.org/getmedia/3275d71c-81dc-4b23-96a703173ecf8446/Recommended_Policy_EDX_Medicine_062810.pdf. Accessed November
23, 2015.
19. American Association of Electrodiagnostic Medicine. Model Policy for Needle
Electromyography and Nerve Conduction Studies. 2010;
https://www.aanem.org/getmedia/89f84ac9-28ec-48af-847f-720b772cb370/2014Model_Policy_NCS_EMG_.pdf. Accessed November 23, 2015.
20. American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM).
Consensus criteria for the diagnosis of multifocal motor neuropathy. 2003;
http://www.aanem.org/Practice/Practice-Guidelines.aspx. Accessed November 23, 2015.
21. American Academy of Orthopaedic Surgeons. OrthoInfo: Electrodiagnostic Testing.
2007; http://orthoinfo.aaos.org/topic.cfm?topic=a00270. Accessed November 23, 2015.
22. Insititute for Clinical Systems Improvement (ICSI). Pain, Chronic: Assessment and
Management of. 2013;
https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/
catalog_neurological_guidelines/pain/. Accessed November 23, 2015.
23. Centers for Medicare and Medicaid Services. Sensory Nerve Conduction Threshold Tests.
2004; http://www.cms.gov/medicare-coverage-database/details/ncddetails.aspx?NCDId=270&ncdver=2&CoverageSelection=National&KeyWord=Sensory
+Nerve+Conduction+Threshold+Tests&KeyWordLookUp=Title&KeyWordSearchType=
And&bc=gAAAABAAAAAAAA%3d%3d&. Accessed November 23, 2015.
Other Sources:
Centers for Medicare and Medicaid Services (CMS). Decision Memo for Electrodiagnostic
Sensory Nerve Conduction Threshold (CAG-00106R). Jul 8, 2003. [Website]:
http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=26 Accessed November 23, 2015
Mosby's Medical, Nursing & Allied Health Dictionary, 6th edition.
Novitas Local Coverage Determination (LCD) 35081: Nerve Conduction Studies and
Electromyography Effective 10/1/15 [Website:] http://www.novitassolutions.com/webcenter/portal/NovitasSolutions?_afrLoop=7927550011680000#!%40%4
0%3F_afrLoop%3D7927550011680000%26_adf.ctrl-state%3D13lwz4xqkf_9
Accessed October 19, 2015.
Novitas Solutions. Local Coverage Determination (LCD). L34996 - Neuromuscular Junction
Testing. Effective 10/1/2015. [Website] http://www.novitassolutions.com/webcenter/portal/NovitasSolutions?_afrLoop=7927550011680000#!%40%4
Page 55
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
Novitas Solutions. Local Coverage Determination (LCD) L34977Anorectal Manometry, Anal
Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or
Urethral Sphincters. Effective 10/1/15 [Website:] http://www.novitassolutions.com/webcenter/portal/NovitasSolutions?_afrLoop=7927550011680000#!%40%
X. POLICY HISTORY
MP-2.063
Top
CAC 1/28/03
CAC 8/31/04
CAC 8/30/05
CAC 10/25/05
CAC 1/31/06
CAC 1/30/07
CAC 3/27/07
CAC 5/27/08
CAC 7/28/09
CAC 9/28/10 Consensus Review
CAC 10/25/11 Consensus Review
CAC 4/12/12 Administrative posting. Medicare variation revised.
2013 Codes added-12/20/2013-sb
8/1/13 administrative change. Added reference to L32943 Anorectal Manometry, Anal
Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or
Urethral Sphincters in the Medicare variation and in reference list.
CAC 1/28/14 Consensus. Policy statement on quantitative sensory testing updated
to include vibration threshold testing and thermal threshold testing as
investigational. Updated Background/Description. Changes to statement did not
result in any coding changes therefore reviewed as consensus. Administrative
coding changes 51784 added.
CAC 1/27/15 Minor revision. Policy retitled “Electromyography and Nerve
Conduction Studies”. BCBSA criteria adopted. EMG/NCS may be considered
medically necessary as an adjunct to clinical examination for the diagnosis of
peripheral neuropathies and myopathies when criteria are met.
Page 56
MEDICAL POLICY
POLICY TITLE
POLICY NUMBER
MP-2.063
The criteria for the following testing was removed from this policy and (3) new
individual policies were created:
 MP-2.097 Paraspinal Surface Electromyography (SEMG) to Evaluate and
Monitor Back Pain
 MP-2.098 Quantitative Sensory Testing
 MP-2.099 Automated Point of Care Testing
11/2/15 Administrative change. LCD numbers changed from L32943, L29547,
L32239 to L34977, L35081, L34996 due to Novitas update to ICD-10.
CAC 1/26/16. Consensus review. No change to policy statements. References and
rationale updated.
8/5/16 Administrative change. Corrected title of MP 2.096 in cross-reference
section. Removed “anal” from title.
Top
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ®,
Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
Page 57

Electromyography and Nerve Conduction Studies

Transcription

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