I'm a member
You will be redirected to myBlue. Would you like to continue?
Please wait while you are redirected.
Please enter a username and password.
Printer Friendly Version
DESCRIPTIONSurface electromyography, a noninvasive procedure that records the summation of muscle electrical activity, has been investigated as a technique to evaluate the physiologic functioning of the back. In addition, this procedure has been studied as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in patients with back pain symptoms, such as spasm, tenderness, limited range of motion, or postural disorders.
Back pain is an extremely common condition, affecting most individuals at some point in their lives. Identifying the pathogenesis of back pain is a challenging task, in part due to the complex anatomy of the back, which includes vertebrae, intervertebral discs, facet joints, spinal nerve roots, and numerous muscles. For example, back pain may be related to osteoarthritis, disc disease, subluxation, or muscular pathology, such as muscle strain or spasm. In addition, due to referred pain patterns, the location of the pain may not be anatomically related to the pathogenesis of the pain. For example, buttock or leg pain may be related to pathology in the spine. In addition to the diagnostic challenges of back pain is the natural history of acute back pain. Most cases of acute low back pain will resolve with conservative therapy, such as physical therapy, and continuing normal activities within limits permitted by the pain. Thus, initial imaging or other diagnostic testing is generally not recommended unless “red flag” warning signs are present or the pain persists for longer than 4 to 6 weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.
Aside from the physical examination, diagnostic tests include imaging technologies, such as magnetic resonance imaging (MRI), designed to identify pathology (e.g., bulging discs), or tests such as discography to localize the abnormality by reproducing the pain syndrome. However, due to their lack of specificity, all diagnostic tests must be carefully interpreted in the context of the clinical picture. For example, 5% of asymptomatic patients will have bulging discs as identified by MRI. Therefore, the presence of a bulging disc may only be clinically significant if well correlated with symptoms. Assessment of the musculature may focus on range of motion or strength exercises.
In contrast to anatomic imaging, surface electromyography (SEMG), which records the summation of muscle activity from groups of muscles, has been investigated as a technique to evaluate the physiologic functioning of the back. SEMG, a noninvasive procedure, is contrasted with needle electromyography, an invasive procedure, in which the electrical activity of individual muscles is recorded.
Paraspinal SEMG has been explored as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in patients with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders. The technique is performed using one (1) or an array of electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises. Recordings can also be made by using a handheld device, which is applied to the skin at different sites. Electrical activity can be assessed by computer analysis of the frequency spectrum (i.e., spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, spectral analysis focusing on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises. Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and has been used to monitor the response to therapy and establish physical activity limits, such as assessing capacity to lift heavy objects or ability to return to work.
Paraspinal SEMG is an office-based procedure that may be most commonly used by physiatrists or chiropractors. The following clinical applications of the paraspinal SEMG have been proposed:
SEMG devices approved by the U.S. Food and Drug Administration (FDA) include those that use a single electrode or a fixed array of multiple surface electrodes.
Several FDA-approved devices combine SEMG along the spine with other types of monitors. For example, in 2007, the Insight Discovery (Fasstech, Burlington, MA) was cleared for marketing through the 510(k) process. The device contains 6 sensor types, 1 of which is for SEMG. The indications include measuring bilateral differences in SEMG along the spine and measuring SEMG along the spine during functional tasks. (Earlier Insight models had fewer sensor types.)
See Electromyography (EMG) policy
POLICYParaspinal surface electromyography (SEMG) is considered investigational as a technique to diagnose or monitor back pain.
POLICY EXCEPTIONSFederal Employee Program (FEP) may dictate that all FDA-approved devices, drugs or biologics may not be considered investigational and thus these devices may be assessed only on the basis of their medical necessity.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY7/1993: Approved by Medical Policy Advisory Committee (MPAC)
8/1997: Reviewed by MPAC
6/22/2001: Managed Care Requirements deleted, EMG hyperlink inserted, table added to Code Reference section
2/13/2002: Investigational definition added
5/8/2002: Type of Service and Place of Service deleted
5/23/2002: Code Reference section completed, CPT code 96002 added, HCPCS S3900 added
6/23/2004: Policy reviewed
8/15/2005: Code Reference section updated, CPT code 96003 added
4/18/2006: Policy updated
2/14/2008: Policy reviewed, no changes
04/16/2010: "To Evaluate and Monitor Back Pain" added to the policy title. Policy description updated. The verbiage “and is not eligible for coverage” deleted from the policy statement; intent unchanged. FEP verbiage added to the Policy Exceptions section. Deleted outdated references from Sources section.
12/28/2010: Policy reviewed; no changes.
01/17/2012: Policy reviewed; no changes.
03/13/2013: Policy reviewed; no changes.
10/25/2013: Policy reviewed; no changes.
10/28/2014: Policy reviewed; description updated regarding acute low back pain. Policy statement unchanged.
08/03/2015: Code Reference section updated for ICD-10.
12/04/2015: Policy description updated regarding devices. Policy statement unchanged. Investigative definition updated in policy guidelines section. Sources section updated to remove Blue Cross Blue Shield Association policy # 2.01.03 as a reference.
06/01/2016: Policy number A.2.01.35 added.
Blue Cross Blue Shield Association policy # 2.01.35
CODE REFERENCEThis may not not be a comprehensive list of procedure codes applicable to this policy.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.