Highmark Medicare Advantage Medical Policy in West Virginia

Section:	CMS National Guidelines
Number:	N-88
Topic:	Sensory Nerve Conduction Threshold Tests (sNCTs) - NCD 160.23
Effective Date:	December 20, 2007
Issued Date:	January 26, 2009

General Policy

The sensory nerve conduction threshold test (sNCT) (G0255) is a psychophysical assessment of both central and peripheral nerve functions. It measures the detection threshold of accurately calibrated sensory stimuli. This procedure is intended to evaluate and quantify function in both large and small caliber fibers for the purpose of detecting neurologic disease. Sensory perception and threshold detection are dependent on the integrity of both the peripheral sensory apparatus and peripheral-central sensory pathways. In theory, an abnormality detected by this procedure may signal dysfunction anywhere in the sensory pathway from the receptors, the sensory tracts, the primary sensory cortex, to the association cortex. This procedure is different and distinct from assessment of nerve conduction velocity (NCV), amplitude and latency. It is also different from short-latency somatosensory evoked potentials.

Indications and Limitations of Coverage

The use of any type of sensory nerve conduction threshold test device (e.g., “current output” type device used to perform current perception threshold (CPT) testing, pain perception threshold (PPT) testing, 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 is not medically necessary and not eligible for coverage. Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

G0255

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual Pub. 100-03, Chapter 1, Section 160.23, Rev. 15, 06/18/04

www.cms.gov

www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

ICD-10 Diagnosis Codes

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.