Medical Policy: 02.01.15
Original Effective Date: February 2000
Reviewed: July 2015
Revised: July 2015
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.
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.
Paraspinal surface EMG (SEMG) is an office based procedure that may be most commonly used by physiatrists or chiropractors. SEMG 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. The following clinical applications of the paraspinal SEMG have been proposed:
- Clarification of a diagnosis (i.e. muscle, joint or disc disease)
- Selection of a course of medical therapy
- Selection of a type of physical therapy
- Preoperative evaluation
- Postoperative rehabilitation
- Follow up of acute low back pain
- Evaluation of exacerbation of chronic low back pain
- Evaluation of pain management treatment techniques
There are inadequate data on the technical and diagnostic performance of paraspinal surface electromyography (EMG) compared with criterion standard reference test. Moreover, there is insufficient evidence regarding how findings from paraspinal SEMG impact patient management and/or how use of the test improves health outcomes. Thus, paraspinal surface electromyography for diagnosing and monitoring back pain is considered investigational.
Practice Guidelines and Position Statements
American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM)
AANEM Evidenced Based Review: Use of Surface Electromyography in the Diagnosis and Study of Neuromuscular Disorders:
- On the basis of two class III studies, sEMG may be useful to detect the presence of neuromuscular disease (Level C: possibly effective, ineffective or harmful for the given condition in the specified population)
- The data are insufficient to determine the clinical utility of sEMG for distinguishing between neuropathic and myopathic conditions or for detecting the more specific neuromuscular conditions of post-poliomyelitis syndrome, pathologic fasciculations, acquired demyelinating peripheral neuropathy, amyotrophic lateral sclerosis, myotonic dystrophy, and hypokalemic periodic paralsysis (Level U: data inadequate or conflicting given current knowledge, treatment is unproven)
- The data are insufficient to address the question of disease severity detectable by sEMG (Level U: data inadequate or conflicting given current knowledge, treatment is unproven)
- The data are insufficient to compare diagnostic utility of sEMG with the conventional technologies of nEMG, NCS and muscle ultrasonography (Level U: data inadequate or conflicting given current knowledge, treatment is unproven)
Further research is necessary to determine the clinical utility of sEMG in the diagnosis of neuromuscular diseases and in the differentiation of primary myopathic and neuropathic conditions.
American College of Occupational and Environmental Medicine (ACOEM)
In a 2011 guideline from the American College of Occupational and Environmental Medicine (ACOEM), surface electromyography is not recommended as a technique for diagnosing low back disorders due to insufficient evidence of efficacy.
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 criterion standard reference test. Also, there is insufficient evidence regarding how findings from paraspinal SEMG impact patient management and/or how use of the test improves health outcomes. Therefore, paraspinal surface electromyography for diagnosing and monitoring back pain is considered investigational.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- S3900 Surface electromyography (EMG)
- 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.
- 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.
- Enomoto M, Ukegawa D, Sakaki K, et al. Increase in paravertebral muscle activity in lumbar kyphosis patients by surface electromyography compared with lumbar spinal canal stenosis patients and healthy volunteers. J Spinal Disord Tech. 2012 Aug;25(6):E167-73.
- American Association of Neuromuscular and Electrodiagnostic Medicine Evidenced Based Review: use of Surface Electromyography in the Diagnosis and Study of Neuromuscular Disorders, April 2008
- Neblett R, Brede E, Mayer TG et al. What is the best surface EMG measure of lumbar flexion-relaxation for distinguishing chronic low back pain patients from pain-free controls? Clin J Pain 2013; 29(4):334-40.
- National Guideline Clearinghouse. American College of Occupational and Environmental Medicine (ACOEM), Low Back Disorders, 2011. p. 333-796
Date Reason Action
September 2010 Annual review Policy renewed
October 2011 Annual review Policy renewed
October 2012 Annual review Policy renewed
September 2013 Annual review Policy renewed
July 2014 Annual review Policy renewed
July 2015 Annual review Policy revised
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
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*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.