Medical Policy: 02.01.15
Original Effective Date: February 2000
Reviewed: June 2020
Revised: November 2016
This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.
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.
Surface electromyography (sEMG) technologies have been studied as a complement or potential alternative to needle electromyography (nEMG) and nerve condition studies (NCS) for the investigation of neuromuscular disorders and 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 sEMG recording techniques vary significantly, but all involve analysis of myoelectrical signals using sensors positioned on the skin surface.
Surface electromyography (sEMG) is also referred to as surface scanning EMG, is a non-invasive, computer-based technique that records the electrical impulses using electrodies placed on the surface of the skin overlying the nerve at rest (i.e. static) and during activity (i.e. dynamic). The procedure studies the topography of the motor unit action potential (MUAP) and is assessed by computer analysis of the frequency spectrum, amplitude or root mean square of the electrical action potential. The sEMG differs from needle electromyography (nEMG) with respect to technical requirements and electrical properties. sEMG electrodes measure from a wide area of muscle, have a relatively narrow frequency band (range 20 to 500 Hz), have a low-signal resolution, and are highly susceptible to movement artifact. The proposed use for this type of EMG is to aid in the diagnosis of neuromuscular disorders and low back pain, and to aid in assessing the prognosis of disorders involving muscle lesions. The technology has also been used to monitor bruxism (i.e. grinding and clenching of teeth). The electrical activity of muscle may be recorded with surface EMG, although spontaneous electrical activity and voluntary motor units cannot be. The clinical utility of surface EMG has not been proven in the peer-reviewed medical literature.
High-density surface electromyography (HD-sEMG) is a non-invasive technique to measure electrical muscle activity with multiple (more than 2) closely spaced electrodes overlying a restricted area of the skin. Besides temporal activity, HD-sEMG also allows spatial EMG activity to be recorded, thus expanding the possibilities to detect new muscle characteristics. Muscle fiber conduction velocity (MFCV) measurements and the evaluation of single motor unit (MU) characteristics come into view. In principle, HD-sEMG allows pathological changes at the MU level to be detected, especially changes in neurogenic disorders and channelopathies. The clinical effectiveness of HD-sEMG has not been established; well- designed studies are needed to ascertain the clinical utility of HD-sEMG.
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.
Paraspinal sEMG, also referred to as paraspinal EMG scanning, has been investigated as a method of assessing the paraspinal muscles of patients which provide support to the spinal column. Impairment of the paraspinal muscles may lead to abnormal motion and pain. The paraspinal sEMG is performed using a single electrode or an array of electrodes placed on the skin surface with recordings that are typically made at rest, in various positions or after physical activity.
Paraspinal surface EMG (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:
The diagnostic utility of paraspinal sEMG is not known, and its role in patient management has not been established.
There is insufficient evidence in the medical literature to support the use of any type of surface electromyography (sEMG) as the diagnostic utility is unknown and the role in patient management has not been established. Further well-designed clinical trials are needed to standardize sEMG approaches and diagnostic algorithms, increase diagnostic performance and to assess the role of sEMG in clinical practice. Therefore this testing is considered investigational for all indications.
AANEM Evidenced Based Review: Use of Surface Electromyography in the Diagnosis and Study of Neuromuscular Disorders:
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.
In 2019 the American College of Occupational and Environmental Medicine (ACOEM), updated their practice guideline for diagnostic tests for low back disorders which states the following: Surface electromyography (sEMG) has been used to diagnose LBP and involves the recording of summated muscle electrical activity by skin electrodes (such as those used in an electrocardiogram or EKG). There are four moderate-quality studies incorporated into this analysis and no quality evidence of diagnostic efficacy, and thus, is not recommended to diagnose LBP. (Not Recommended, Insufficient Evidence (I), High Confidence).
Surface electromyography (sEMG) including but not limited to the following, for any indication is considered investigational.
There is insufficient evidence in the medical literature to support the use of any type of surface electromyography (sEMG) as the diagnostic utility is unknown and the role in patient management has not been established. Further well-designed clinical trials are needed to standardize sEMG approaches and diagnostic algorithms, increase diagnostic performance and to assess the role of sEMG in clinical practice. The evidence is insufficient to determine the effects of this technology on net health outcomes.
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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.
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