Print

Date Printed: August 23, 2017: 06:08 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-95805-19

Original Effective Date: 11/15/08

Reviewed: 10/27/11

Revised: 05/11/14

Subject: Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References  

DESCRIPTION:

Surface electromyography (SEMG), 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 (ROM), or postural disorders.

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. The majority of 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 4-6 weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.

Aside from physical exam, diagnostic tests include imaging technologies, such as magnetic resonance imaging (MRI), designed to identify abnormal 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 physiological 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, also referred to as paraspinal EMG scanning, 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 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 also 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:

• Clarification of a diagnosis (i.e., muscle, joint, or disc disease)

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 surface EMG 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 surface EMG. The indications include measuring bilateral differences in surface EMG along the spine and measuring surface EMG along the spine during functional tasks. (Earlier Insight models had fewer sensor types).

POSITION STATEMENT:

Paraspinal Surface Electromyography (EMG) to evaluate and monitor back pain is considered experimental or investigational. There is minimal published literature to support clinical utility or permit scientific conclusions regarding the long-term efficacy of this procedure on health outcomes.

BILLING/CODING INFORMATION:

The following code may be used to describe paraspinal surface electromyography:

CPT Coding:

There is no specific CPT code for surface electromyography (SEMG) (other than 96002, dynamic surface electromyography, during walking or other functional activities, 1–12 muscles, which is part of the CPT coding for motion analysis). Existing codes for EMG (95860-95872) explicitly describe needle EMG, in which a needle is inserted into an individual muscle. Therefore, these codes do not describe surface EMG.

HCPCS Coding:

S3900

Surface electromyography (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L29288) located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. AHRQ/National Guideline Clearinghouse. NGC-007160 Chronic pain. American College of Occupational and Environmental Medicine (ACOEM); 2008. p. 73-502.
  2. AHRQ/National Guideline Clearinghouse. NGC-007408. Management of whiplash associated disorders. International Chiropractors Association of California; 2009.
  3. American Chiropractic Association, The Subcommittee for Ethical Practice: Guide for Insurance Professionals. 03/06/06. (Accessed 09/23/11).
  4. Blue Cross Blue Shield Association. Medical Policy Reference Manual. Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain. 11/10. (Accessed 09/21/11).
  5. ClinicalTrials.gov. NCT00728572, Logan Basic Technique Measured by Surface Electromyography (EMG). Logan College of Chiropractic. Last Updated on August 22, 2008. (Accessed 09/23/11).
  6. ClinicalTrials.gov. Art and Surface Electromyography (EMG), Logan College of Chiropractic. Last Updated on July 31, 2009. (Accessed 09/23/11).
  7. ECRI. Custom Hotline Response. Surface Electromyography for Evaluating Back Pain. Plymouth Meeting, PA: ECRI. Updated 03/18/08.
  8. Fife TD, Tusa R J, Furman JM, et al. Assessment: Vestibular testing techniques in adults and children: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Neurology 2000;55;1431. (Accessed 09/21/11).
  9. Florida Medicare Part B Local Coverage Determination. L29288 Noncovered Services. 02/02/09. Last updated 08/11/09. (Accessed 09/21/11).
  10. Florida Medicare Part B Local Coverage Determination. L5780 NCSVCS The List of Medicare Noncovered Services. 07/01/08.
  11. Geisser ME, Ranavaya M, Haig AJ, Roth RS, Zucker R, Ambroz C, Caruso M. A meta-analytic review of surface electromyography among persons with low back pain and normal, healthy controls. J Pain. 2005 Nov; 6(11): 711-26.
  12. Hayes, Inc. Hayes Medical Technology Directory. Surface Electromyography for Evaluation of Low Back Pain. Lansdale, PA: Hayes, Inc.; Dec 2006. Update performed 01/05/08.
  13. Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM); 2007. p. 366.
  14. Pullman SL, Goodin DS, Marquinez AI, Tabbal S, Rubin M. Clinical utility of surface EMG: report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology. 2000 Jul 25; 55(2): 171-7. (Accessed 09/21/11).
  15. Ritvanen T, Zaproudina N, Nissen M, Leinonen V, Hänninen O. Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy. J Manipulative Physiol Ther. 2007 Jan; 30(1): 31-7. Erratum in: J Manipulative Physiol Ther. 2007 Jul-Aug; 30 (6): 472.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/27/11.

GUIDELINE UPDATE INFORMATION:

11/15/08

New Medical Coverage Guideline.

11/15/09

Scheduled review; no change in position statement, and update references.

11/15/11

Scheduled review; updated description section, added CPT coding statement and updated references.

05/11/14

Revision: Program Exceptions section updated.

Date Printed: August 23, 2017: 06:08 AM