MEDICAL POLICY

POLICY
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POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain

Number 2.01.35

Effective Date November 10, 2014

Revision Date(s) 11/10/14; 11/11/13; 01/14/13

Replaces 2.01.516

Policy

Paraspinal surface electromyography (SEMG) is considered investigational as a technique to diagnose or monitor back pain.

Related Policies

2.01.03

Gait Analysis

8.03.501

Chiropractic Services

Policy Guidelines

There is no specific CPT code for SEMG (other than 96002: Dynamic surface electromyography, during walking or other functional activities, 1 to 12 muscles, which is part of the CPT coding for motion analysis). Existing codes for EMG (95860-95872) explicitly describe needle EMG, in which a needle is inserted into an individual muscle. Therefore, These codes do not describe surface EMG.

Coding

CPT

95999

Unlisted neurological or neuromuscular diagnostic procedure

96002

Dynamic surface electromyography, during walking or other functional activities, 1 to 12 muscles, which is part of the CPT coding for motion analysis

97799

Unlisted physical medicine/rehabilitation service or procedure

99199

Unlisted special service, procedure, or report

HCPCS

S3900

Surface electromyography (EMG)

Description

Surface electromyography (SEMG), a noninvasive procedure that records the summation of muscle electrical activity, has been investigated as a technique to evaluate the physiologic functioning of the back. In addition, this procedure has been studied 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.

Background

Back pain is an extremely common condition, affecting most individuals at some point in their lives. Identifying the pathogenesis of back pain is a challenging task, in part due to the complex anatomy of the back, which includes vertebrae, intervertebral discs, facet joints, spinal nerve roots, and numerous muscles. For example, back pain may be related to osteoarthritis, disc disease, subluxation, or muscular pathology, such as muscle strain or spasm. Moreover, due to referred pain patterns, the location of the pain may not be anatomically related to the pathogenesis of the pain. For example, buttock or leg pain may be related to pathology in the spine. In addition to the diagnostic challenges of back pain is the natural history of acute back pain. Most cases of acute low back pain will resolve with conservative therapy, such as physical therapy, and continuing normal activities within limits permitted by the pain. Thus, initial imaging or other diagnostic testing is generally not recommended unless “red flag” warning signs are present or the pain persists for longer than 4 to 6 weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.

Aside from physical examination, diagnostic tests include imaging technologies, such as magnetic resonance imaging (MRI), designed to identify pathology (e.g., bulging discs) or tests such as discography to localize the abnormality by reproducing the pain syndrome. However, due to their lack of specificity, all diagnostic tests must be carefully interpreted in the context of the clinical picture. For example, 5% of asymptomatic patients will have bulging discs as identified by MRI. Therefore, the presence of a bulging disc may only be clinically significant if well correlated with symptoms. Assessment of the musculature may focus on range of motion or strength exercises.

In contrast to anatomic imaging, SEMG, which records the summation of muscle activity from groups of muscles, has been investigated as a technique to evaluate the physiologic functioning of the back. A noninvasive procedure, SEMG is contrasted with needle electromyography, an invasive procedure in which the electrical activity of individual muscles is recorded. Paraspinal SEMG 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 1 or an array of electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises. Recordings can also be made by using a handheld device, which is applied to the skin at different sites. Electrical activity can be assessed by computer analysis of the frequency spectrum (ie, spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, spectral analysis that focuses on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises. Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and also has 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.

Paraspinal 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:

  • 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

Regulatory Status

SEMG devices approved by FDA include those that use a single electrode or a fixed array of multiple surface electrodes.

Several FDA-approved devices combine surface EMG along the spine with other types of monitors. For example, in 2007, the Insight Discovery (Fasstech, Burlington, MA) was cleared for marketing through the 510(k) process. The device contains 6 sensor types, 1 of which is surface EMG. The indications include measuring bilateral differences in surface EMG along the spine and measuring surface EMG along the spine during functional tasks. (Earlier Insight models had fewer sensor types.) FDA product code: IKN.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

N/A

Rationale

This policy was originally created in 2000 and was updated regularly with searches of the MEDLINE database. Most recently, the literature was reviewed through July 29, 2014. Following is a summary of the key literature to date:

Surface electromyography (SEMG) has been used as a research tool to evaluate the performance of paraspinal muscles in patients with back pain and to further understand the etiology of low back pain. (1-4) Preliminary research has also been performed on which SEMG parameters best differentiate between patients with and without back pain. (5, 6) However, validation of its use as a clinical diagnostic technique involves a sequential 3-step procedure as follows:

  1. Technical performance of a device is typically assessed by studies that compare test measurements with a criterion standard and those that compare results taken with the same device on different occasions (test-retest).
  2. Diagnostic performance is evaluated by the ability of a test to accurately diagnose a clinical condition in comparison with the criterion standard. The sensitivity of a test is the ability to detect a disease when the condition is present (true-positive), while specificity indicates the ability to detect patients who are suspected of disease but who do not have the condition (true-negative). Evaluation of diagnostic performance, therefore, requires independent assessment by the 2 methods in a population of patients who are suspected of disease but who do not all have the disease.
  3. Evidence related to improvement of clinical outcomes with use of this testing assesses the data linking use of a test to changes in health outcomes (clinical utility). While in some cases, tests can be evaluated adequately using technical and diagnostic performance, when a test identifies a new or different group of patients with a disease; randomized trials are needed to demonstrate impact of the test on the net health outcome.

The following discussion focuses on these three steps as they apply to SEMG.

Technical Performance

Several studies using different SEMG devices have suggested that paraspinal SEMG, in general, is a reliable technique, based on coefficients of variation or test-retest studies. (1, 7) No studies were identified that compared the performance of SEMG to a criterion standard reference test.

Diagnostic Performance

No articles that compare the results of SEMG (which tests groups of muscles) with needle electromyography (which tests individual muscles) for diagnosing any specific muscle pathology were identified in literature searches. However, the pathology of individual muscles (i.e., radiculopathy, neuropathy may represent a different process than the pathology of muscle groups (i.e., muscle strain, spasm), and thus SEMG may be considered by its advocates as a unique test for which there is currently no criterion standard. Nevertheless, even if one accepts this premise, there are inadequate data to evaluate the diagnostic performance of SEMG. For example, no articles were identified in the published peer-reviewed literature that established definitions of normal or abnormal SEMG. In some instances, asymmetrical electrical activity may have been used to define abnormality; results may be compared with normative data. However, there was no published literature defining what degree of asymmetry would constitute abnormality or how a normative database was established. (8)

In the absence of a criterion standard diagnostic test, correlation with the clinical symptoms and physical exam is critical. De Luca published a series of studies investigating a type of SEMG called the Back Analysis System (BAS), consisting of surface electrodes and other components to measure the electrical activity of muscles during isometric exercises designed to produce muscle fatigue. (2) Using physical exam and clinical history as a criterion standard, the author found that the BAS was able to accurately identify control and back pain patients 84% and 91% of the time, respectively, with the values increasing to 100% in some populations of patients. (Accuracy is the sum of true-positive and true-negative results.) However, these studies were not designed as a clinical diagnostic tool per se but were intended to investigate the etiology of back pain and to investigate muscular fatigue patterns in patients with and without back pain.

Hu et al. in Hong Kong published 2 articles on dynamic topography, an approach to analyzing SEMG findings. (9,10) The studies had similar protocols. Both included low-back pain patients and healthy controls; all participants underwent SEMG at study enrollment and then back pain patients participated in a rehabilitation program. The first study found different dynamic topography at baseline between healthy people and people with back pain, e.g., a more symmetric pattern in healthy controls. (9) After physical therapy, the dynamic topography images of back pain patients were more similar to the healthy controls on some of the parameters that were assessed. In the second study, following rehabilitation, back pain patients were classified as responders or nonresponders based on changes in back pain severity. (10) Some associations were found between baseline SEMG parameters and response to rehabilitation. SEMG was not repeated following the rehabilitation program, and thus it is not clear whether there are any significant associations between continued symptoms and SEMG abnormalities. Moreover, it is not clear how SEMG analysis would affect treatment decisions for low back pain patients.

Improvement of Clinical Outcomes

Several articles describe the use of SEMG as an aid in classifying low back pain. (11-13) Much of this research has focused on the use of spectral analysis to assess muscle fatigability rather than how information from SEMG could enhance patient management. While SEMG may be used to objectively document muscle spasm or other muscular abnormalities, it is unclear how such objective documentation would supplant or enhance clinical evaluation, or how this information would be used to alter the treatment plan. In part, the difficulty in clinical interpretation is understanding the extent to which the SEMG abnormalities are primary or secondary. In addition, as noted in the Background section, no specific workup is recommended for acute low back pain without warning signs.

There are no data regarding the impact of SEMG on the final health outcome. For example, SEMG has been proposed as a technique to differentiate muscle spasm from muscle contracture, with muscle spasm treated with relaxation therapy and contracture treated with stretching exercises. However, there are no data to validate that such treatment suggested by SEMG resulted in improved outcomes. (14, 15)

A literature review of spinal muscle evaluation in low back pain patients, published in 2007, indicated that the validity of SEMG remains controversial. (16) The authors note that although many studies show increased fatigability of the paraspinal muscles in patients with low back pain, it is not known whether these changes are causes or consequences of the low back pain. Also, the utility of SEMG is limited because of the inability to clearly define normal versus abnormal profiles due to factors such as a lack of normative data.

Summary of Evidence

There are inadequate data on the technical and diagnostic performance of paraspinal surface electromyography (SEMG) compared with a 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

In a 2011 guideline from the American College of Occupational and Environmental Medicine, surface electromyography is not recommended as a technique for diagnosing low back disorders due to insufficient evidence of efficacy. (17)

U.S. Preventive Services Task Force Recommendations

Paraspinal surface electromyography is not a preventive service.

Medicare National Coverage

There is no national coverage determination (NCD). In the absence of an NCD, coverage decisions are left to the discretion of local Medicare carriers.

References

  1. Cram JR, Lloyd J, Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom. 1994; 41(4-Jan):41-45. PMID
  2. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve. 1993; 16(2):210-216. PMID
  3. Jones SL, Hitt JR, Desarno MJ, et al. Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations. Exp Brain Res. Sep 2012; 221(4):413-426. PMID 22875027
  4. Sheeran L, Sparkes V, Caterson B, et al. Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain: classification analysis. Spine (Phila Pa 1976). Apr 15 2012; 37(8):E486-495. PMID 22024899
  5. Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. Oct 2011; 3(10):920-928. PMID 22024323
  6. 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. Apr 2013; 29(4):334-340. PMID 23328325
  7. Ahern DK, Follick MJ, Council JR, et al. Reliability of lumbar paravertebral EMG assessment in chronic low back pain. Arch Phys Med Rehabil. 1986; 67(10):762-765. PMID
  8. Gentempo P, Kent C. Establishing medical necessity for paraspinal EMG scanning. Chiropractic: J Chiropractic Res Clin Invest. 1990; 3(1):22-25. PMID
  9. Hu Y, Siu SH, Mak JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyogr Kinesiol. 2010; 20(2):246-255. PMID
  10. Hu Y, Kwok JW, Tse JY, et al. Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation. Spine J. Jun 1 2014;14(6):1049-1056. PMID 24530438
  11. Humphrey AR, Nargol AV, Jones AP, et al. The value of electromyography of the lumbar paraspinal muscles in discriminating between chronic-low-back-pain sufferers and normal subjects. Eur Spine J. 2005; 14(2):175-184. PMID
  12. Peach JP, McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine. 1998; 23(10):1117-1123. PMID
  13. Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther. 1998; 78(8):838-851. PMID
  14. Ellestad SM, Nagle RV, Boesler DR, et al. Electromyographic and skin resistance responses to osteopathic manipulative treatment for low-back pain. J Am Osteopath Assoc. 1988; 88(8):991-997. PMID
  15. Bittman B, Cram JR. Surface electromyography: an electrophysiologic alternative in pain management. Presented at the American Pain Society; 1992; Illinois.
  16. Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine. 2007; 74(1):9-13. PMID
  17. American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. Available online at: www.guideline.gov. Last accessed October 13, 2014.
  18. Blue Cross and Blue Shield Association (BCBSA) Medical Policy Reference Manual, Paraspinal Surface Electromyography (SEMG) to Evaluate and Monitor Back Pain. Medical Policy Reference Manual, Policy 2.01.35, 2013.

Coding

Codes

Number

Description

CPT

95999

Unlisted neurological or neuromuscular diagnostic procedure

 

96002

surface electromyography, during walking or other functional activities, 1–12 muscles

 

97799

Unlisted physical medicine/rehabilitation service or procedure

 

99199

Unlisted special service, procedure, or report

HCPCS

S3900

Surface electromyography (EMG)

Type of Service

Medicine

 

Place of Service

Outpatient

 

Appendix

N/A

History

Date

Reason

05/08/12

New policy, add to Medicine section. This policy replaces 2.01.516.

07/27/12

Add Related Policy 2.01.03

08/27/12

Update Coding Section – ICD-10 Codes are now effective 10/01/2014.

01/29/13

Replace policy. Policy updated with literature search. No changes to policy statement. References 3-5 and 17 added; other references re-numbered or removed. Add Related Policy 8.03.501.

12/04/13

Replace policy. Policy guidelines reformatted for usability. Rationale updated with literature search through July 25, 2013. Reference 6 added; other references renumbered or removed. Policy statement unchanged.

11/20/14

Annual Review. Policy updated with literature review through July 29, 2014. No changes to policy statement. Reference 10 added. Codes 95860-70, & 95872 removed; these do not suspend specifically relate to the policy; ICD-9 and ICD-10 diagnosis codes removed as they are not utilized in adjudication of the policy.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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