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Date Printed: June 28, 2017: 11:42 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: 05/28/09

Revised: 11/01/15

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. QST systems measure and quantify the amount of physical stimuli required for sensory perception to occur in the patient. Stimuli used in QST includes touch, pressure, pain, thermal (warm and cold), or vibratory stimuli. Depending on the type of stimuli used, QST can assess small or large fiber dysfunction. QST with touch and vibration can evaluate large myelinated A alpha and A beta sensory fibers. Thermal stimuli can assess small myelinated fibers and unmyelinated sensory nerve function.

QST is used to assist in the diagnosis and management of a variety of conditions such as diabetic neuropathy and other uremic and toxic neuropathies, as well as carpal tunnel syndrome and other nerve entrapment/compression disorders or damage. QST has not been established for use as a sole tool for diagnosis and management but has been used in conjunction with standard evaluation and management procedures (e.g., physical and neurological examination, monofilament testing, pinprick, grip and pinch strength, Tinel, Phalen and Roos sign) to enhance the diagnosis and treatment planning process and confirm physical findings with quantifiable data. As sensory deficits increase, the perception threshold of QST will increase, which may be informative in documenting progression of neurologic damage or disease.

Because QST combines the objective physical sensory stimuli with the subject patient response, it is psychophysical in nature and requires that its use be in patients who are alert, able to follow directions, and cooperative. Due to the subjective component of testing, psychological factors must be taken into consideration during testing and in evaluating test results, thus reducing the degree of objectivity QST can provide.

Two QST methods are highlighted in this policy: current perception threshold testing and pressure-specified sensory device testing.

Current Perception Threshold Testing

Current perception threshold testing, also referred to as sensory nerve conduction threshold (sNCT) testing, involves the quantification of the sensory threshold to transcutaneous electrical stimulation and thus has been explored as a technique to evaluate the sensory nerves. Current perception threshold testing falls into the general category of quantitative sensory testing (QST). Other modalities of QST focus on perception of thermal or vibratory stimuli. In current perception threshold testing, typically 3 different frequencies are tested: 5 Hz, designed to assess C fibers; 250 Hz, designed to assess A – delta fibers; and 2,000 Hz, designed to assess the A – beta fibers. Current perception threshold testing has been investigated for a broad range of clinical applications, including evaluation of peripheral neuropathies, detection of carpal tunnel syndrome, spinal radiculopathy, evaluation of the effectiveness of peripheral nerve blocks, quantification of hypoesthetic and hyperesthetic conditions and differentiation of psychogenic from neurologic disorders.

The Neurometer┬« Current Perception Threshold (Neurotron, Inc) and the Medi-Dx 7000™ (Neuro Diagnostic Associates), are 2 devices approved by the U.S. Food and Drug Administration (FDA) for the use of current perception threshold testing for sensory nerve conduction.

Pressure-Specified Sensory Testing

Pressure-specified sensory testing is a method to assess nerve function by quantifying the thresholds of pressure detected with light, static, and moving touch. The Nk Pressure-Specified Sensory Device™ (Nk Biotechnical Engineering) consists of 1 or 2 blunt probes and sensitive transducers to measure and record the perception thresholds of pressure on the surface of the body in grams per square millimeter. The device has been used to aid in the diagnosis and assessment of nerve function, including diabetic peripheral neuropathy, carpal tunnel syndrome, and other nerve entrapment or compression syndromes, and postoperative assessment of sensory outcomes after liposuction, breast reduction mammaplasty. The Nk Pressure-Specified Sensory Device™ received FDA 510(k) marketing clearance in August 1994 (K934368).

POSITION STATEMENT:

Quantitative sensory testing, including current perception threshold testing and pressure-specified sensory device testing, is considered experimental or investigational, as there is insufficient clinical evidence to support the use of quantitative sensory testing. There is inadequate scientific literature to support conclusions regarding the effects of quantitative sensory testing, including current perception threshold testing and pressure-specified sensory device testing, on net 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)

0108T

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 (L29288) located at fcso.com.

DEFINITIONS:

Current perception threshold testing: also referred to as sensory nerve conduction threshold testing (sNCT) involves the quantification of the sensory threshold to transcutaneous electrical stimulation and thus has been explored as a technique to evaluate the sensory nerves; falls into the general category of quantitative sensory testing. Typically, three different frequencies are tested: 5 Hz, 250 Hz, and 2,000 Hz.

Hyperesthetic: unusual or pathological sensitivity of the skin or of a particular sense to stimulation.

Hypoesthetic: impaired or decreased tactile sensibility.

Radiculopathy: any diseased condition of roots of spinal nerves.

RELATED GUIDELINES:

Nerve Conduction Studies; F-Wave Studies; H-Reflex Studies, 01-95805-02

OTHER:

Other names used to report Current Perception Threshold Test:

Note: 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.

CPT test
Medi-DX 7000™
Neurometer®
QST
Quantitative Sensory Testing
Sensory Nerve Conduction Threshold Test

REFERENCES:

  1. American Association of Electrodiagnostic Medicine, American Academy of Neurology, and American Academy of Physical Medicine and Rehabilitation. Recommended policy for Electrodiagnostic Medicine, updated 2004.
  2. American Medical Association Current Procedural Terminology (CPT) 2005. Chicago, IL.
  3. Blue Cross Blue Shield Association. Medical Policy Reference Manual. 2.01.39 Quantitative Sensory Testing, 04/09/08.
  4. Centers for Medicare and Medicaid Services (CMS) Manual System, Pub. 100-3, Medicare National Coverage, Chapter 1, Part 2, Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs), (04/01/04).
  5. ECRI, Sensory Nerve Conduction Threshold Tests (Including Current Perception Threshold and Voltage Nerve Conduction Threshold Tests), 12/20/06.
  6. England JD, Gronseth GS, Franklin G, et al, Distal Symmetric Polyneuropathy: A Definition for Clinical Research: Report of the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation, Neurology 2005; 64; 199-207, accessed at neurology.org on 04/07/09.
  7. First Coast Service Options, Inc., Article for Quantitative Sensory Testing (QST) – 0107T (A48474), 02/02/09.
  8. First Coast Service Options, Inc., LCD for The List of Medicare Noncovered Services (L29288), 03/02/09.
  9. 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.
  10. Medicare Coverage Decision Memorandum for Electrodiagnostic Sensory Nerve Conduction Threshold (CAG-00106N), 02/14/02.
  11. Shy ME, Frohman EM, So YT, Arezzo JC, Cornblath DR, Giuliani MJ, Kincaid JC, Ochoa JL, Parry GJ, Weimer LH; Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Quantitative sensory testing: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2003 Mar 25; 60(6): 898-904.
  12. Technology review: the Neurometer Current Perception Threshold (CPT). AAEM Equipment and Computer Committee. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1999 Apr; 22(4): 523-31.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 05/28/09.

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.

Date Printed: June 28, 2017: 11:42 PM