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Medical Policy: 02.01.15
Original Effective Date: February 2000
Reviewed: October 2011
Revised: August 2004
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
The difficulty in identifying the source of pathology for most low back pain disorders has led researchers to develop new technology to help in the diagnosis of low back pain. Assessment approaches based on paraspinal surface electromyography signal techniques have been proposed to overcome some of the problems identified in other technologies. The concept is to measure and identify the presence of abnormal muscle functioning in a manner that will suggest a form of treatment.
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 single or multiple electrodes placed on the skin surface with recordings made either at rest, in various positions, or after a series of exercises. Recordings can also be made by using a hand-held device, which is applied to the skin at different sites.
Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and has also 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.
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Prior Approval:
Not applicable
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Policy:
Paraspinal surface electromyography is considered investigational as a technique to diagnose or monitor back pain. The scientifc evidence is not adequate to permit conclusions regarding the efficacy of this technology.
There are inadequate data on the technical and diagnostic performance of paraspinal SEMG compared to a gold standard reference test. There is also insufficient evidence regarding how findings from paraspinal SEMG impact patient management and/or how use of the test improves health outcomes.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- S3900 Surface electromyography (EMG)
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Selected References:
- Hemingway MA, Biedermann H-J, Inglis J. Electromyographic Recordings of Paraspinal muscles: Variations Related to Subcutaneous Tissue Thickness. Biofeedback and Self-Regulation, vol. 20, no.1, 1995:39-49.
- Roy SH, Oddsson LI. Classification of Paraspinal Muscle Impairments by Surface Electromyography. Physical Therapy, vol.78, no. 8, Aug1998:838-851.
- Pullman SL, Goodin DS, et al. 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.
- Merlo A, Farina D, Member, IEEE, Merletti R. A fast reliable technique for muscle activity detection from surface EMG signals. IEEE Transactions on Biomedical Engineering 2003;50(3):316-323.
- Lehman GJ.Clinical considerations in the use of surface eletromyographpy: Three experimental studies. J Manipulative Physiol Ther 2002;25:293-299.
- Lariviere C, Arsenault AB, Gravel D, Gagnon D, Loisel P, Vadeboncoeur R. Elecromyographic assessment of back muscle weakness and muscle composition: Reliability and validity issues. Arch Phys Med Rehabil 2002;83:1206-1214.
- Stokes IAF, Henry SM, Single RM. Surface EMG electrodes do not accurately record from lumber multifidus muscles. Clinical Biomechanics 2003;18:9-1.
- American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee Report; Clinical Utility of Surface EMG. © 2002
- ECRI. Surface Electromyography for Evaluating Back Pain. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 18. 11p. Also available: http://www.ecri.org.
- American Academy of Neurology Clinical Utility of Surface EMG. Technology assessment report. Neurology2000 July 25;55(2):171-7. This information is current as of April 10, 2009. The online version of this article, along with updated information and services, is located on the World Wide Web at:http://www.neurology.org/cgi/content/full/55/2/171
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Policy History:
Date Reason Action
September 2010 Annual review Policy renewed
October 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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