Highmark Commercial Medical Policy in West Virginia

Section: Diagnostic Medical
Number: M-51
Topic: Nerve Conduction Velocity (NCV) Studies
Effective Date: April 1, 2011
Issued Date: July 2, 2012
Date Last Reviewed: 06/2012

General Policy Guidelines

Indications and Limitations of Coverage

Nerve conduction velocity (NCV) studies may be indicated for the following conditions:

  1. Focal neuropathies or compressive lesions, for localization.
  2. Traumatic nerve lesions, for diagnosis and prognosis.
  3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic, or immune.
  4. Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, myasthenic syndrome.
  5. Differential diagnosis of symptom-based complaints (e.g., pain in limb, weakness, disturbance in skin sensation or paresthesia) provided the clinical assessment supports the need for a study.

NCV studies are eligible for reimbursement when performed for any of the indications listed in the Text Attachment below. When performed for other conditions, NCV studies are considered not medically necessary. A participating, preferred or network 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 should be maintained in the provider's records.

An F-Wave (95903) is considered a form of nerve conduction testing. When reported independently, it should be processed according to the number of nerves studied.

H-reflex testing (95934, 95936) can be paid separately from the NCV studies listed under procedure codes 95900-95904. Payment should be limited to one unilateral or bilateral study per session per code.

Neuromuscular junction testing (repetitive stimulation) should be processed separately under procedure code 95937. Payment should be limited to two repetitive stimulations per session.

Payment higher than the established allowance for an NCV study (95900-95904) should not be made if a doctor reports that multiple methods (e.g., surface and needle electrodes) or multiple sites were used, or that an anatomical crossover existed (e.g., a median nerve is stimulated but the ulnar nerve is affected). None of these constitute a circumstance of such an unusual nature as to warrant additional payment.

Non-invasive electrodiagnostic testing with an automated computerized hand-held device (95905)(e.g., NC-stat®) to stimulate and measure neuromuscular signals is considered experimental/investigational in the diagnosis and evaluation of systemic and entrapment neuropathies. Scientific evidence does not show that motor and/or sensory nerve conduction using preconfigured electrode arrays (such as testing like that done with the NC-stat® device) is equivalent to traditional nerve conduction study methods. Automated, non-invasive nerve conduction testing is therefore not covered and is not eligible for payment. A participating, preferred, or network provider can bill the member for this non-covered service. 

Refer to Medical Policy Bulletin M-28 for information on Electromyography (EMG).

Description

A nerve conduction velocity study aids in diagnosing peripheral nerve injuries and diseases affecting the peripheral nervous system. To measure nerve conduction time, a nerve is stimulated electronically through the skin and underlying tissue.

Results of NCV studies reflect on the integrity and function of the myelin sheath (covering of a nerve fiber) and the axon (an impulse conducting extension neurons) of the nerve. Damage or destruction of the axon usually results in loss of nerve or muscle amplitude potential. Demyelination (damage or destruction of the myelin sheath) leads to prolongation of nerve conduction time.


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.

Procedure Codes

959009590395904959059593495936
95937     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical Policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

National Blue Cross Blue Shield Association Medical Policy 2.01.77, Automated Point-of-Care Nerve Conduction tests

Clinical and Electrodiagnostic Testing of Carpal Tunnel Syndrome: A Narrative Review, The Journal of Orthopedic and Sports Physical Therapy, Volume 34, Number 10, 10/2004

Median and Ulnar Nerve Conduction Measurement in Patients with Symptoms of Diabetic Peripheral Neuropathy Using the NC-Stat System, Diabetes Technology & Therapeutics, Volume 6, Number 6, 12/2004

Clinical Utility of Portable Versus Traditional Electrodiagnostic Testing for Diagnosing, Evaluating, and Treating Carpal Tunnel Syndrome, American Journal of Orthopedics, Volume34, Number 8, 08/2005

Proper Performance and Interpretation of Electrodiagnostic Studies, American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), Muscle & Nerve, Volume 33, Number 3, 2006.

NC-Stat Sensory Nerve Conduction Studies in the Median and Ulnar Nerves of Symptomatic Patients, Clinical Neurophysiology: official journal of the International Federation of Clinical Neurophysiology, Volume 117, Number 2, 02/2006

NC-Stat as a Screening Tool for Carpal Tunnel Syndrome in Industrial Workers, The Journal of Occupational and Environmental Medicine / American College of Occupational and Environmental Medicine, Volume 48, Number 8, 04/2006

Validation of a Novel Point-of-Care Nerve Conduction Device for the Detection of Diabetic Sensorimotor Polyneuropathy, Diabetes Care, Volume 29, Number 9, 09/2006

Diabetic Nerve Conduction Abnormalities in the Primary Care Setting, Diabetes Technology & Therapeutics, Volume 8, Number 6, 12/2006

Repeatability of Nerve Conduction Measurements Using Automation, Journal of Clinical Monitoring and Computing, Volume 20, Number 6, 12/2006

Criterion Validity of the NC-Stat Automated Nerve Conduction Measurement Instrument, Physiological Measurement, Volume 28, Number 1, 01/2007

Utility of Nerve Conduction Studies for Carpal Tunnel Syndrome by Family Medicine, Primary Care, and Internal Medicine Physicians, Journal of the American Board of Family Medicine, Volume 20, Number 1, 01-02/2007

Fisher MA, Bajwa R, Somashekar KN. Lumbosacral radiculopathies—the importance of EDX information other than needle electromyography. Electromyogr Clin Neurophysiol. 2007;47(7-8):377-84.

Lesser EA, Starr J, Kong X, et al. Point-of-service nerve conduction studies: an example of industry driven disruptive innovation in health care. Perspec Biol Med. 2007;50(1):40-53.

Armstrong TN, Dale AM, Muhammad T, et al. Median and ulnar nerve conduction studies at the wrist: criterion validity of the NC-stat automated device. Journal of Occupational and Environmental Medicine. 2008;50(7):758-64.

Perkins BA, Orszag A, Grewal J, et al. Multi-Site testing with a point-of-care nerve conduction device can be used in an algorithm to diagnose diabetic sensorimotor polyneuropathy. Diabetes Care. 2008;31(3):522-4.

Keith MW, Masear V, Chung K, et al. Diagnosis of carpal tunnel syndrome. J Am Acad Orthop Surg. 2009;17(6):389-96.

Horowitz SH. Overview of nerve conduction studies. UpToDate. April 2012.

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Table Attachment

Text Attachment


Procedure Code Attachments

Diagnosis Codes

ICD-9 Diagnosis Codes

Covered Diagnosis Codes

Nerve Conduction Velocity Studies (95900, 95903, 95904, 95934, 95936, 95937)

138250.60-250.63332.0333.6
333.83333.90335.10-335.11335.19
335.20-335.24335.29335.8335.9
336.0-336.3336.8-336.9337.00337.09
337.1340344.00-344.01344.60-344.61
350.2350.9 351.0351.8-351.9
352.1-352.6353.0353.1353.2-353.4
353.5353.8353.9354.0-354.5
354.8-354.9355.0-355.6 355.71355.79
355.8355.9 356.0-356.4356.8-356.9
357.0-357.7357.81-357.89357.9358.00-358.01
358.1-358.2358.8-358.9359.0-359.1359.21-359.29
359.3-359.6359.81359.89359.9
710.3710.4719.41-719.48721.0-721.3
721.41-721.42721.5-721.8721.90-721.91722.0
722.10-722.11722.2722.4722.51-722.52
722.6722.70-722.73722.80-722.83722.90-722.93
723.0723.1 723.4723.9
724.01724.02724.03724.2
724.3 724.4724.5 728.0
728.9 729.1729.2 729.5
738.4 781.2782.0787.60
952.00-952.09952.10-952.19952.2952.3
952.4952.8952.9953.0-953.5
953.8-953.9 954.0-954.1954.8-954.9955.0-955.9
956.0-956.5956.8-956.9957.0-957.1957.8-957.9
959.01959.09959.11-959.19959.2
959.7-959.8   

ICD-10 Diagnosis Codes

INFORMATIONAL ONLY

Covered Diagnosis Codes

A52.15B91E08.40E08.42
E08.44E09.40E09.42E09.44
E10.40E10.41E10.42E10.43
E10.44E10.49E10.610E10.65
E11.40E11.41E11.42E11.43
E11.44E11.49E11.610E11.65
E13.40E13.41E13.42E13.43
E13.44E13.49E13.610G12.1
G12.20G12.21G12.22G12.29
G12.8G12.9G13.0G13.1
G14G20G21.4G24.1
G24.3G25.9G32.0G32.8
G35G50.1G51.0G51.2
G51.3G51.4G51.8G51.9
G52.1G52.2G52.3G52.7
G52.8G54.0G54.1G54.2
G54.3G54.4G54.5G54.8
G54.9G55G56.00G56.01
G56.02G56.10G56.11G56.12
G56.20G56.21G56.22G56.30
G56.31G56.32G56.40G56.41
G56.42G56.80G56.81G56.82
G56.90G56.91G56.92G57.70
G57.71G57.72G57.80G57.81
G57.82G57.90G57.91G57.92
G58.0G58.7G60.0G60.1
G60.2G60.3G60.8G60.9
G61.0G61.1G61.81G61.89
G61.9G62.0G62.1G62.2
G62.81G62.82G62.89G62.9
G63G64G65.0G65.1
G65.2G70.00G70.01G70.1
G70.2G70.8G70.9G71.0
G71.11G71.12G71.13G71.14
G71.19G71.2G71.3G71.8
G71.9G72.0G72.1G72.2
G72.3G72.81G72.89G72.9
G73.3G73.7G82.50G82.51
G83.4G90.09G95.0G95.11
G95.19G95.20G95.29G95.81
G95.89G95.9G99.0G99.2
M05.40M05.411M05.412M05.419
M05.421M05.422M05.429M05.431
M05.432M05.439M05.441M05.442
M05.449M05.451M05.452M05.459
M05.461M05.462M05.469M05.471
M05.472M05.479M05.49M05.50
M05.511M05.512M05.519M05.521
M05.522M05.529M05.531M05.532
M05.539M05.541M05.542M05.549
M05.551M05.552M05.559M05.561
M05.562M05.569M05.571M05.572
M05.579M05.59M25.50M25.511
M25.512M25.519M25.521M25.522
M25.529M25.531M25.532M25.539
M25.551M25.552M25.559M25.561
M25.562M25.569M25.571M25.572
M25.579M25.78M33.00M33.01
M33.02M33.09M33.10M33.11
M33.12M33.19M33.20M33.21
M33.22M33.29M33.90M33.91
M33.92M33.99M34.82M34.83
M35.03M36.0M46.40M46.41
M46.42M46.43M46.44M46.45
M46.46M46.47M46.48M46.49
M47.011M47.012M47.013M47.014
M47.015M47.016M47.019M47.021
M47.022M47.029M47.10M47.11
M47.12M47.13M47.14M47.15
M47.16M47.17M47.18M47.20
M47.21M47.22M47.23M47.24
M47.25M47.26M47.27M47.28
M47.811M47.812M47.813M47.814
M47.815M47.816M47.817M47.818
M47.819M47.891M47.892M47.893
M47.894M47.895M47.896M47.897
M47.898M47.899M47.9M48.01
M48.02M48.03M48.04M48.05
M48.06M48.07M48.10M48.11
M48.12M48.13M48.14M48.15
M48.16M48.17M48.18M48.19
M48.20M48.21M48.22M48.23
M48.24M48.25M48.26M48.27
M48.30M48.31M48.32M48.33
M48.34M48.35M48.36M48.37
M48.38M48.9M50.00M50.01
M50.02M50.03M50.10M50.11
M50.12M50.13M50.20M50.21
M50.22M50.23M50.30M50.31
M50.32M50.33M50.80M50.81
M50.82M50.83M50.90M50.91
M50.92M50.93M51.04M51.05
M51.06M51.07M51.14M51.15
M51.16M51.17M51.24M51.25
M51.26M51.27M51.34M51.35
M51.36M51.37M51.84M51.85
M51.86M51.87M51.9M54.11
M54.12M54.13M54.14M54.15
M54.16M54.17M54.5M60.000
M60.001M60.002M60.003M60.004
M60.005M60.009M60.011M60.012
M60.019M60.021M60.022M60.029
M60.031M60.032M60.039M60.041
M60.042M60.043M60.044M60.045
M60.046M60.051M60.052M60.059
M60.061M60.062M60.069M60.070
M60.071M60.072M60.073M60.074
M60.075M60.076M60.077M60.078
M60.08M60.09M60.80M60.811
M60.812M60.819M60.821M60.822
M60.829M60.831M60.832M60.839
M60.841M60.842M60.849M60.851
M60.852M60.859M60.861M60.862
M60.869M60.871M60.872M60.879
M60.88M60.89M60.9M79.1
M79.601M79.602M79.603M79.604
M79.605M79.606M79.609M79.621
M79.622M79.629M79.631M79.632
M79.639M79.641M79.642M79.643
M79.644M79.645M79.646M79.651
M79.652M79.659M79.661M79.662
M79.669M79.671M79.672M79.673
M79.674M79.675M79.676M79.7
M96.1M99.20M99.21M99.22
M99.23M99.30M99.31M99.32
M99.33M99.40M99.41M99.42
M99.43M99.50M99.51M99.52
M99.53M99.60M99.61M99.62
M99.63M99.70M99.71M99.72
M99.73R15.9R20.0R20.1
R20.2R20.3R20.8R20.9
R26.0R26.1R26.81R26.89
R26.9S09.10xAS09.11xAS09.19xA
S09.8xxAS09.90xAS09.92xAS09.93xA
S14.0xxAS14.101AS14.102AS14.103A
S14.104AS14.105AS14.106AS14.107A
S14.108AS14.109AS14.111AS14.112A
S14.113AS14.114AS14.115AS14.116A
S14.117AS14.118AS14.119AS14.121A
S14.122AS14.123AS14.124AS14.125A
S14.126AS14.127AS14.128AS14.129A
S14.131AS14.132AS14.133AS14.134A
S14.135AS14.136AS14.137AS14.138A
S14.139AS14.141AS14.142AS14.143A
S14.144AS14.145AS14.146AS14.147A
S14.148AS14.149AS14.151AS14.152A
S14.153AS14.154AS14.155AS14.156A
S14.157AS14.158AS14.159AS14.2xxA
S14.3xxAS14.4xxAS14.5xxAS14.8xxA
S14.9xxAS16.8xxAS16.9xxAS19.80xA
S19.81xAS19.82xAS19.83xAS19.84xA
S19.85xAS19.89xAS19.9xxAS24.0xxA
S24.101AS24.102AS24.103AS24.104A
S24.109AS24.111AS24.112AS24.113A
S24.114AS24.119AS24.131AS24.132A
S24.133AS24.134AS24.139AS24.141A
S24.142AS24.143AS24.144AS24.149A
S24.151AS24.152AS24.153AS24.154A
S24.159AS24.2xxAS24.3xxAS24.4xxA
S24.8xxAS24.9xxAS29.001AS29.002A
S29.009AS29.091AS29.092AS29.099A
S29.8xxAS29.9xxAS34.01xAS34.02xA
S34.101AS34.102AS34.103AS34.104A
S34.105AS34.109AS34.111AS34.112A
S34.113AS34.114AS34.115AS34.119A
S34.121AS34.122AS34.123AS34.124A
S34.125AS34.129AS34.131AS34.132A
S34.139AS34.21xAS34.22xAS34.3xxA
S34.4xxAS34.5xxAS34.6xxAS34.8xxA
S34.9xxAS39.001AS39.002AS39.003A
S39.091AS39.092AS39.093AS39.81xA
S39.82xAS39.83xAS39.840AS39.848A
S39.91xAS39.92xAS39.93xAS39.94xA
S44.00xAS44.01xAS44.02xAS44.10xA
S44.11xAS44.12xAS44.20xAS44.21xA
S44.22xAS44.30xAS44.31xAS44.32xA
S44.40xAS44.41xAS44.42xAS44.50xA
S44.51xAS44.52xAS44.8x1AS44.8x2A
S44.8x9AS44.90xAS44.91xAS44.92xA
S46.001AS46.002AS46.009AS46.091A
S46.092AS46.099AS46.101AS46.102A
S46.109AS46.191AS46.192AS46.199A
S46.201AS46.202AS46.209AS46.291A
S46.292AS46.299AS46.301AS46.302A
S46.309AS46.391AS46.392AS46.399A
S46.801AS46.802AS46.809AS46.891A
S46.892AS46.899AS46.901AS46.902A
S46.909AS46.991AS46.992AS46.999A
S49.80xAS49.81xAS49.82xAS49.90xA
S49.91xAS49.92xAS54.00xAS54.01xA
S54.02xAS54.10xAS54.11xAS54.12xA
S54.20xAS54.21xAS54.22xAS54.30xA
S54.31xAS54.32xAS54.8x1AS54.8x2A
S54.8x9AS54.90xAS54.91xAS54.92xA
S64.00xAS64.01xAS64.02xAS64.10xA
S64.11xAS64.12xAS64.20xAS64.21xA
S64.22xAS64.30xAS64.31xAS64.32xA
S64.40xAS64.490AS64.491AS64.492A
S64.493AS64.494AS64.495AS64.496A
S64.497AS64.498AS64.8x1AS64.8x2A
S64.8x9AS64.90xAS64.91xAS64.92xA
S74.00xAS74.01xAS74.02xAS74.10xA
S74.11xAS74.12xAS74.20xAS74.21xA
S74.22xAS74.8x1AS74.8x2AS74.8x9A
S74.90xAS74.91xAS74.92xAS84.00xA
S84.01xAS84.02xAS84.10xAS84.11xA
S84.12xAS84.20xAS84.21xAS84.22xA
S84.801AS84.802AS84.809AS84.90xA
S84.91xAS84.92xAS86.001AS86.002A
S86.009AS86.091AS86.092AS86.099A
S86.101AS86.102AS86.109AS86.191A
S86.192AS86.199AS86.201AS86.202A
S86.209AS86.291AS86.292AS86.299A
S86.301AS86.302AS86.309AS86.391A
S86.392AS86.399AS86.801AS86.802A
S86.809AS86.891AS86.892AS86.899A
S86.901AS86.902AS86.909AS86.991A
S86.992AS86.999AS89.80xAS89.81xA
S89.82xAS89.90xAS89.91xAS89.92xA
S94.00xAS94.01xAS94.02xAS94.10xA
S94.11xAS94.12xAS94.20xAS94.21xA
S94.22xAS94.30xAS94.31xAS94.32xA
S94.8x1AS94.8x2AS94.8x9AS94.90xA
S94.91xAS94.92xAS96.001AS96.002A
S96.009AS96.091AS96.092AS96.099A
S96.101AS96.102AS96.109AS96.191A
S96.192AS96.199AS96.201AS96.202A
S96.209AS96.291AS96.292AS96.299A
S96.801AS96.802AS96.809AS96.891A
S96.892AS96.899AS96.901AS96.902A
S96.909AS96.991AS96.992AS96.999A
S99.811AS99.812AS99.819AS99.821A
S99.822AS99.829AS99.911AS99.912A
S99.919AS99.921AS99.922AS99.929A
T07   

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 Highmark West Virginia 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.

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