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Date Printed: October 20, 2017: 02:04 PM

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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.

01-95805-18

Original Effective Date: 11/15/01

Reviewed: 07/27/17

Revised: 08/15/17

Subject: Quantitative Sensory Testing

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 Updates    
           

DESCRIPTION:

Quantitative sensory testing (QST) systems are used for the noninvasive assessment and quantification of sensory nerve function in patients with symptoms of or the potential for neurologic damage or disease. Types of sensory testing include current perception threshold testing, pressure-specified sensory testing, vibration perception threshold testing, and thermal sensory testing. Information on sensory deficits identified using QST has been used in research settings and has primarily been applied in patients with conditions associated with nerve damage and neuropathic pain. There have also been preliminary investigations to identify sensory deficits associated with other conditions such as autism spectrum disorder, Tourette syndrome, restless legs syndrome, musculoskeletal pain, and response to opioid treatment. The proposed clinical utility of QST is to improve the diagnosis of conditions associated with nerve damage or disease and to positively change patient management. There is a need for tests that can objectively measure sensory thresholds and potentially aid in the early diagnosis of disease.

POSITION STATEMENT:

Quantitative sensory testing, including but not limited to current perception threshold testing, pressure-specified sensory device testing, vibration perception threshold testing, and thermal threshold testing, is considered experimental or investigational. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

0106T

Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation (investigational)

0107T

Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation (investigational)

Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia (investigational)

 

0109T

Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia (investigational)

0110T

Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation (investigational)

HCPCS Coding:

G0255

Current perception threshold/sensory nerve conduction test, per limb, any nerve (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 National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Sensory Nerve Conduction Threshold Tests (sNCTs) (160.23) located at cms.gov.

The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

Current perception threshold testing: involves the quantification of the sensory threshold to transcutaneous electrical stimulation. Typically 3 different frequencies are tested: 5 Hz, designed to assess C fibers; 250 Hz, designed to assess A delta fibers; and 2000 Hz, designed to assess A beta fibers. Results are compared with those of a reference population.

Pressure-specified sensory testing: used to assess large myelinated sensory nerve function by quantifying the thresholds of pressure detected with light, static, and moving touch.

Thermal sensory testing: used to evaluate pathology of small myelinated and unmyelinated nerve fibers; they can be used to assess heat and cold sensation, as well as thermal pain thresholds.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. Abraham A, Albulaihe H, Alabdali M, et al. Elevated Vibration Perception Thresholds in CIDP Patients Indicate More Severe Neuropathy and Lower Treatment Response Rates. PLoS One. 2015;10(11):e0139689.
  2. American Association of Electrodiagnostic Medicine, American Academy of Neurology, and American Academy of Physical Medicine and Rehabilitation. Recommended policy for Electrodiagnostic Medicine, updated 2004.
  3. Blue Cross Blue Shield Association Medical Policy Reference Manual. 2.01.39 Quantitative Sensory Testing, 06/17.
  4. Centers for Medicare & Medicaid Services (CMS), NCD for Sensory Nerve Conduction Threshold Tests (sNCTs) (160.23), accessed cms.gov 06/13/17.
  5. ClinicalTrials.gov, Assessment of Small Fiber Neuropathy in Rare Diseases Using Sudoscan, sponsored by Massachusetts General Hospital, accessed 06/15/17.
  6. ClinicalTrials.gov, SudoScan as a Biomarker of Parkinson's Disease, sponsored by McGill University Health Center, accessed 06/15/17.
  7. ClinicalTrials.gov, Vascular and Neurologic Exploration of Small Nervous Fiber by Sudoscanner, sponsored by Groupe Hospitalier Paris Saint Joseph, accessed 06/15/17.
  8. Cruccu G, Sommer C, Anand P, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. Eur J Neurol. Aug 2010;17(8):1010-1018.
  9. England JD, Gronseth GS, Franklin G, et al. Distal symmetrical polyneuropathy: definition for clinical research. Muscle Nerve. Jan 2005;31(1):113-123.
  10. First Coast Service Options, Inc.(FCSO) LCD for Noncovered Services (L33777), accessed at fcso.com 06/13/17.
  11. Hayes, Inc. Hayes Search & Summary. Neural-Scan™ NCSs System™ (Neuro-Diagnostic Associates [NDA] Inc.) as a Screening Procedure for the Detection of Peripheral Neuropathy. Lansdale, PA: Hayes, Inc.; 12/28/07.
  12. Shy ME, Frohman EM, So YT, et al. Quantitative sensory testing: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. Mar 25 2003;60(6):898-904.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/27/17.

GUIDELINE UPDATE INFORMATION:

11/15/01

Medical Coverage Guideline 01-95805-02 Nerve Conduction Studies; F-wave Studies; H-reflex Studies reformatted and revised.

12/15/02

Added coverage information for current perception threshold testing (G0255).

10/15/03

Annual Review; developed separate MCG for Current Perception Threshold Testing.

10/15/04

Scheduled review and revision; consisting of updated references.

10/15/05

Scheduled review and revision; consisting of updated references.

09/15/06

Scheduled review and revision; consisting of updated references and maintaining investigational statement. MCG name changed from Current Perception Threshold Testing to Quantitative Sensory Testing.

07/15/07

Annual review; investigational status maintained, reformatted guideline, references updated.

07/15/08

Review and revision; consisting of updated references.

06/15/09

Annual review: position statement maintained, and updated references.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

08/15/17

Review; investigational status maintained; description section and references updated.

Date Printed: October 20, 2017: 02:04 PM