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DESCRIPTIONNerve conductions studies (NCS) and needle electromyography (EMG), when properly performed by a trained practitioner, are considered the gold standard of electrodiagnostic testing. However, the need for specialized equipment and personnel may limit the availability of electrodiagnostic testing for some patients. Portable devices have been developed to provide point-of-care nerve conduction studies. These portable devices have computational algorithms that are able to drive stimulus delivery, measure and analyze the response, and provide a detailed report of study results. Automated nerve conduction could be used in various settings, including primary care, without the need for specialized training or equipment.
One proposed use of automated nerve conduction devices is to assist in the diagnosis of carpal tunnel syndrome (CTS). CTS is a pressure-induced entrapment neuropathy of the median nerve as it passes through the carpal tunnel, resulting in sensorimotor disturbances. This syndrome is defined by its characteristic clinical symptoms, which may include pain, subjective feelings of swelling and nocturnal parasthesia. A variety of simple diagnostic tools are available, and a positive response to conservative management (steroid injection, splints, and modification of activity) can confirm the clinical diagnosis. Electrodiagnostic studies may also be used to confirm the presence or absence of a median neuropathy at the wrist, assess the severity of the neuropathy, and assess alternate associated diagnoses. Nerve conduction is typically assessed prior to surgical release of the carpal tunnel, but the use of electromyography in the diagnosis of CTS is controversial.
Point-of-care nerve conduction testing has also been proposed for the diagnosis of peripheral neuropathy and, in particular, for detecting neuropathy in patients with diabetes. Peripheral neuropathy is relatively common in patients with diabetes mellitus, and the diagnosis is often made clinically through the physical examination. Diabetic peripheral neuropathy can lead to important morbidity including pain, foot deformity, and foot ulceration. Clinical practice guidelines recommend using simple sensory tools such as the 10-g Semmes-Weinstein monofilament or the 128-Hz vibration tuning fork for diagnosis. These simple tests predict the presence of neuropathy defined by electrophysiological criteria with a high level of accuracy. Electrophysiological testing may be used in research studies and may be required in cases with an atypical presentation.
NC-stat® by NeuroMetrix is a portable nerve conduction test device designed to be used at the point-of-care. The system comprises a biosensor array, an electronic monitor, and a remote report generation system. The biosensor is a single use, preconfigured array consisting of a stimulation anode and cathode, skin surface digital thermometer, and response sensor. Biosensor arrays are available for assessment of sensory and motor nerves of the wrist (median and ulnar), and for the foot (peroneal, posterior tibial, and sural). A chip imbedded in the biosensor panel measures skin surface temperature, the analysis algorithm adjusts for differences in temperature from 30º C, or if skin surface temperature is less than 23º C the monitor will indicate that limb warming is necessary. Data are sent to a remote computer via a modem in the docking station, and the remote computer generates a report based on the average of 6 responses that is sent back by fax or email. In addition to the automated stimulus delivery and reporting, NC-stat® analysis adjusts the calculation for body temperature, height, and weight, and uses the average of 6 responses. Sensitivity of the device for sensory nerve amplitude potentials is 2.1 µV, values lower than this are analyzed as zero, and responses with artifact are automatically eliminated from the analysis.
Several devices are now being marketed for point-of-care neural conduction testing. NeuroMetrix received specific clearance to market NC-stat® via the U.S. Food and Drug Administration's (FDA) 510(k) process in 1998, listing as predicate devices the TECA model-10 electromyograph and the Neurometer by Neurotron, which measures vibration threshold. The FDA-listed intended use was "to measure neromuscular signals that are useful in diagnosing and evaluating systemic and entrapment neuropathies." In addition, the approved application stated that "The NC-stat is intended to be used as an adjunct to and not a replacement for conventional electrodiagnostic measurements." NeuroMetrix subsequently received FDA clearance to market newer models with biosensors and engineering changes that enable the NC-stat to be used for motor and sensory nerves of the wrist (median and ulnar) and foot (peroneal, tibial, and sural). The intended use as listed on the 510(k) approval from 2006 (#K060584) is "to stimulate and measure neuromuscular signals that are useful in diagnosing and evaluating systemic and entrapment neuropathies."
The XLTek Neuropath (Excel-Tech) received clearance for marketing through the FDA's 510(k) process in 2006; the indications are the same as those for NC-stat. The Neural-ScanTM NCS (Excite Medical) is a Class I diagnostic device (FDA clearance not usually required) that is being marketed "as part the [sic] neurological examination or for screening to detect peripheral neuropathies."
Examples of devices used for automated point-of-care nerve conduction studies that are not eligible for coverage as discussed in this policy are listed below. This is not an all-inclusive list.
Automated point-of-care devices not listed above, but are equivalent to these devices, are also not eligible for coverage.
Studies have shown the correlation of portable automated nerve conduction tests results with standard testing; however, questions remain about the diagnostic performance and clinical utility (i.e., impact on outcomes) of point-of-care automated testing. Particularly needed are data on the sensitivity and specificity of automated nerve conduction tests performed by non-specialists at the point-of-care in comparison with the "gold standard" of laboratory NCS/EMG. One potential clinical use could be early identification of asymptomatic diabetic neuropathy to institute appropriate clinical management before the onset of ulcerations, but no studies were identified that assessed the influence of point-of-care nerve conductions tests on clinical outcomes in this population. Overall, evidence remains insufficient to evaluate the effect of automated point-of-care nerve conduction test on health outcomes. Therefore, automated point-of-care conduction tests are considered investigational.
POLICYAutomated nerve conduction tests are considered investigational.
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.
POLICY GUIDELINESNerve conduction studies performed without needle electromyography studies, unless contraindicated (i.e., an individual receiving anticoagulant therapy) are considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY3/2/2007: Policy added
3/22/2007: Reviewed and approved by Medical Policy Advisory Committee (MPAC)
6/14/2007: Code Reference section updated per quarterly HCPCS and Category III revisions
10/11/2007: Code Reference section reviewed. CPT 95900, 95903, and 95904 removed from policy as non-covered for an automated point of care nerve conduction test (Note: Standard nerve conduction tests may be covered with these Copts); a specific HCPCS code for an automated point of care nerve conduction test became effective 7-1-2007
7/6/2009: Policy reviewed, description updated, policy statement unchanged
11/03/2010: Policy description section revised to provide a list of devices and research findings regarding portable automated nerve conduction tests compared to standard testing. Policy statement unchanged. FEP verbiage added to the Policy Exceptions section. Added the following statement to the Policy Guidelines: Nerve conduction studies performed without needle electromyography studies, unless contraindicated (i.e., an individual receiving anticoagulant therapy) are considered investigational. Code Reference section revised to add 95905, 95999, and G0255 to the Non-Covered Codes Table. A note was also added to state that CPT Codes 95900, 95903 and 95904 should not be used to bill for automated nerve conduction testing.
08/02/2011: Policy reviewed; no changes.
07/17/2012: Policy reviewed; no changes.
09/03/2013: Policy reviewed; no changes.
SOURCE(S)Blue Cross Blue Shield Association Policy # 2.01.77
CODE REFERENCEThis is may not be a comprehensive list of procedure codes applicable to this policy.