Aetna Nerve Conduction Studies coverage criteria

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

Coverage criteria

• Nerve conduction studies (NCS) considered medically necessary when member has ANY of the listed indications AND disease-specific criteria (where applicable) are met.
• NCS indication: Diagnosis and prognosis of traumatic nerve lesions (e.g., spinal cord injury, trauma to nerves).
• NCS indication: Diagnosis and monitoring of neuromuscular junction disorders (e.g., myasthenia gravis, myasthenic syndrome) using repetitive nerve stimulation.
• NCS indication: Diagnosis of muscle disorders (e.g., muscular dystrophy, myositis, myopathy).
• NCS indication: Diagnosis or confirmation of suspected generalized neuropathies (including uremic, metabolic or immune) (e.g., Guillain-Barre Syndrome, post-polio syndrome).
• NCS indication: Differential diagnosis of physical examination findings of sensory loss, weakness and/or muscle atrophy with no known etiology (e.g., amyotrophic lateral sclerosis, diabetes, hypothyroidism, lupus, rheumatoid arthritis).
• NCS indication: Differential diagnosis of symptom-based complaints (e.g., pain in limb or joint, weakness, fatigue, cramps, twitching [fasciculations], disturbance in skin sensation or paresthesias [numbness or tingling]) provided the clinical assessment supports the need for a study.
• NCS indication: Localization of focal neuropathies or compressive lesions (e.g., Bell's palsy of the facial nerve, carpal tunnel syndrome, cubital tunnel syndrome, tarsal tunnel syndrome, nerve root compression, neuritis, motor neuropathy, mononeuropathy, radiculopathy, plexopathy).
• NCS indication: Peripheral neuropathy (e.g., distal symmetric polyneuropathy) — unexplained peripheral neuropathy with pain of a neuropathic pattern, and with demonstrated motor loss or sensory loss, all of unknown etiology.
• Carpal tunnel syndrome (suspected) evaluation — requires (ALL of): (1) Sensory conduction studies across the wrist with a conduction distance of 13-14 cm of the median nerve, and if results are abnormal, of one other sensory nerve in the symptomatic limb; AND (3) Motor conduction studies of the median nerve recording from the thenar muscle and of one other nerve in the symptomatic limb to include measurement of distal latency.
• Carpal tunnel syndrome — if the initial median sensory NCS across the wrist has a conduction distance greater than 8 cm and results are within normal limits, ONE of the following additional studies is medically necessary: (a) comparison of median sensory conduction across the wrist with radial or ulnar sensory conduction across the wrist in the same limb; OR (b) comparison of the median sensory or mixed nerve conduction with ulnar sensory nerve conduction across the wrist over a short (7-8 cm) conduction distance; OR (c) comparison of median nerve conduction through the carpal tunnel to proximal or distal segments of the median nerve in the same limb.
• Cervical, thoracic or lumbar radiculopathy evaluation — requires ALL of: (1) persistent or progressive symptoms; AND (2) failed non-surgical medical management with at least 6 weeks of formal in-person physical therapy in the past year (not home or virtual PT), confirmed by actual PT notes or member claims history; AND (3) unexplained by imaging studies (e.g., MRI, myelogram).
• Cubital tunnel syndrome — for individuals with symptoms and positive physical signs of distribution region of the ulnar nerve (e.g., pain and numbness of the forearm and finger, weakness of hands and muscle atrophy). Note: if ulnar sensory or motor NCS are abnormal, further NCSs should be performed to exclude a diffuse process.
• Distal symmetric polyneuropathy (DSP) suspected — medically necessary when ANY of: (1) presentation does not indicate an etiology (e.g., history and physical plus standard neuropathy blood tests for common/treatable causes such as diabetes [glucose, HbA1c], vitamin deficiencies [B12], autoimmune conditions [SPEP]); OR (2) symptoms and/or physical findings are moderate to severe; OR (3) atypical presentation (motor, asymmetric, or proximal deficits); OR (4) rapid progression of symptoms or signs; OR (5) discrepancy between signs and symptoms; OR (6) history of exposure to medications (e.g., taxanes, lithium) or toxins known to cause neuropathy; OR (7) familial history of hereditary neuropathy affecting first-degree family members; OR (8) underlying severity and duration of etiology; and/or (9) overlapping symptoms or signs to suspect another diagnosis (e.g., radiculopathy).
• Needle electromyography (EMG) performed concurrently with NCS is medically necessary when the above NCS criteria are met (including disease-specific criteria when applicable).
• Standard needle (monopolar or concentric) EMG — the requirement for needle EMG with NCS may be WAIVED for persons with coagulation disorders or on anti-coagulant therapy with warfarin (Coumadin), direct thrombin inhibitors (e.g., dabigatran [Pradaxa], desirudin [Iprivask]), or heparins that cannot be interrupted.
• Single fiber EMG — for the evaluation of neuromuscular disorders (i.e., Myasthenia Gravis [MG] and Lambert-Eaton Myasthenic Syndrome [LEMS]). Reporting should include neuromuscular jitter and muscle fiber density (FD).
• Neuromuscular junction testing — to diagnose persons with fatigable weakness being evaluated for possible disease of the neuromuscular junction, medically necessary for ANY of: autoimmune neuromyotonia; botulism; congenital myasthenic syndrome; Lambert-Eaton myasthenic syndrome; motor neuropathy (e.g., amyotrophic lateral sclerosis); myasthenia gravis; myopathy; or symptoms of diplopia, dysphagia, or fatigable weakness that increases with repetitive activity. Note: reporting should include the rate of repetition of stimulations and any significant incremental or decremental response.
• Blink reflexes — to evaluate disease involving the 5th or 7th cranial nerves or brainstem. Note: recordings should be made bilaterally with both ipsilateral and contralateral stimulation.
• Frequency: Two tests per year are appropriate per diagnosis for carpal tunnel (unilateral and bilateral), radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disorders.
• Frequency: Three tests per year are appropriate per diagnosis for motor neuronopathy and plexopathy.
• Frequency exceptions allowing testing beyond the annual limits based on physician review: (1) evaluation by more than one EDX physician (e.g., second opinion) in a given year; (2) inconclusive diagnosis; (3) rapidly evolving disease that initial EDX testing may not show abnormality (e.g., early Guillain-Barre syndrome); (4) fluctuating disease course with variable response to treatment; (5) unexpected or changed course of disease (e.g., failure to improve after surgery for radiculopathy); (6) recovery from injury (monitor recovery, prognosticate, determine timing of surgical intervention, e.g., traumatic nerve injury); (7) new set of symptoms (e.g., evaluation for a second diagnosis the same year).

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

• 95907·PA verdict·Rate
• 95908·PA verdict·Rate
• 95909·PA verdict·Rate
• 95910·PA verdict·Rate
• 95911·PA verdict·Rate
• 95912·PA verdict·Rate
• 95913·PA verdict·Rate
• 95933·PA verdict·Rate
• 95937·PA verdict·Rate

Documentation required

• Documentation should include relevant history and physical examination that establish the working diagnosis and need for EDX testing.
• NCS and EMG performed by a physician trained in electrodiagnostic medicine, or by a resident/fellow with direct supervision by an EDX-trained physician, including real-time interpretation by the EDX-trained physician. Only physicians may perform any portion requiring needle insertion (EMG); technologists may perform NCS only.
• NCS performed, reported, and interpreted with the associated needle EMG on-site and in real time in accordance with AMA CPT code requirements for these procedures.
• A full EDX report must be submitted, including all EDX tests performed and data summary tables; forwarding the NCS waveforms is encouraged.
• (Documentation requirements above exclude blink reflexes.)

Frequently asked questions

When does Aetna cover Nerve Conduction Studies (CPT 95907), and what gets it denied?

Aetna CPB 0502 covers electrodiagnostic testing — nerve conduction studies (NCS), needle EMG, neuromuscular junction testing, and blink reflexes — as medically necessary only for specific neurologic indications (e.g., traumatic nerve lesions, neuromuscular junction disorders, muscle disorders, generalized or focal neuropathies, carpal/cubital tunnel and radiculopathy) when defined disease-specific criteria are met, with EMG generally required alongside NCS. Manual/automated point-of-care NCS devices (e.g., NC-stat, DPNCheck, Brevio, Medi-Dx 7000) and several specific indications (e.g., diabetic/ESRD neuropathy screening, COVID-19 neuromuscular disorders, Peyronie's disease) are considered experimental, investigational, or unproven, and testing is also EI/unproven whenever the stated criteria are not met. The bulletin is silent on prior authorization. Coverage criteria include: Nerve conduction studies (NCS) considered medically necessary when member has ANY of the listed indications AND disease-specific criteria (where applicable) are met.; NCS indication: Diagnosis and prognosis of traumatic nerve lesions (e.g., spinal cord injury, trauma to nerves).; NCS indication: Diagnosis and monitoring of neuromuscular junction disorders (e.g., myasthenia gravis, myasthenic syndrome) using repetitive nerve stimulation.; NCS indication: Diagnosis of muscle disorders (e.g., muscular dystrophy, myositis, myopathy).; NCS indication: Diagnosis or confirmation of suspected generalized neuropathies (including uremic, metabolic or immune) (e.g., Guillain-Barre Syndrome, post-polio syndrome).; NCS indication: Differential diagnosis of physical examination findings of sensory loss, weakness and/or muscle atrophy with no known etiology (e.g., amyotrophic lateral sclerosis, diabetes, hypothyroidism, lupus, rheumatoid arthritis).; NCS indication: Differential diagnosis of symptom-based complaints (e.g., pain in limb or joint, weakness, fatigue, cramps, twitching [fasciculations], disturbance in skin sensation or paresthesias [numbness or tingling]) provided the clinical assessment supports the need for a study.; NCS indication: Localization of focal neuropathies or compressive lesions (e.g., Bell's palsy of the facial nerve, carpal tunnel syndrome, cubital tunnel syndrome, tarsal tunnel syndrome, nerve root compression, neuritis, motor neuropathy, mononeuropathy, radiculopathy, plexopathy).; NCS indication: Peripheral neuropathy (e.g., distal symmetric polyneuropathy) — unexplained peripheral neuropathy with pain of a neuropathic pattern, and with demonstrated motor loss or sensory loss, all of unknown etiology.; Carpal tunnel syndrome (suspected) evaluation — requires (ALL of): (1) Sensory conduction studies across the wrist with a conduction distance of 13-14 cm of the median nerve, and if results are abnormal, of one other sensory nerve in the symptomatic limb; AND (3) Motor conduction studies of the median nerve recording from the thenar muscle and of one other nerve in the symptomatic limb to include measurement of distal latency.; Carpal tunnel syndrome — if the initial median sensory NCS across the wrist has a conduction distance greater than 8 cm and results are within normal limits, ONE of the following additional studies is medically necessary: (a) comparison of median sensory conduction across the wrist with radial or ulnar sensory conduction across the wrist in the same limb; OR (b) comparison of the median sensory or mixed nerve conduction with ulnar sensory nerve conduction across the wrist over a short (7-8 cm) conduction distance; OR (c) comparison of median nerve conduction through the carpal tunnel to proximal or distal segments of the median nerve in the same limb.; Cervical, thoracic or lumbar radiculopathy evaluation — requires ALL of: (1) persistent or progressive symptoms; AND (2) failed non-surgical medical management with at least 6 weeks of formal in-person physical therapy in the past year (not home or virtual PT), confirmed by actual PT notes or member claims history; AND (3) unexplained by imaging studies (e.g., MRI, myelogram).; Cubital tunnel syndrome — for individuals with symptoms and positive physical signs of distribution region of the ulnar nerve (e.g., pain and numbness of the forearm and finger, weakness of hands and muscle atrophy). Note: if ulnar sensory or motor NCS are abnormal, further NCSs should be performed to exclude a diffuse process.; Distal symmetric polyneuropathy (DSP) suspected — medically necessary when ANY of: (1) presentation does not indicate an etiology (e.g., history and physical plus standard neuropathy blood tests for common/treatable causes such as diabetes [glucose, HbA1c], vitamin deficiencies [B12], autoimmune conditions [SPEP]); OR (2) symptoms and/or physical findings are moderate to severe; OR (3) atypical presentation (motor, asymmetric, or proximal deficits); OR (4) rapid progression of symptoms or signs; OR (5) discrepancy between signs and symptoms; OR (6) history of exposure to medications (e.g., taxanes, lithium) or toxins known to cause neuropathy; OR (7) familial history of hereditary neuropathy affecting first-degree family members; OR (8) underlying severity and duration of etiology; and/or (9) overlapping symptoms or signs to suspect another diagnosis (e.g., radiculopathy).; Needle electromyography (EMG) performed concurrently with NCS is medically necessary when the above NCS criteria are met (including disease-specific criteria when applicable).; Standard needle (monopolar or concentric) EMG — the requirement for needle EMG with NCS may be WAIVED for persons with coagulation disorders or on anti-coagulant therapy with warfarin (Coumadin), direct thrombin inhibitors (e.g., dabigatran [Pradaxa], desirudin [Iprivask]), or heparins that cannot be interrupted.; Single fiber EMG — for the evaluation of neuromuscular disorders (i.e., Myasthenia Gravis [MG] and Lambert-Eaton Myasthenic Syndrome [LEMS]). Reporting should include neuromuscular jitter and muscle fiber density (FD).; Neuromuscular junction testing — to diagnose persons with fatigable weakness being evaluated for possible disease of the neuromuscular junction, medically necessary for ANY of: autoimmune neuromyotonia; botulism; congenital myasthenic syndrome; Lambert-Eaton myasthenic syndrome; motor neuropathy (e.g., amyotrophic lateral sclerosis); myasthenia gravis; myopathy; or symptoms of diplopia, dysphagia, or fatigable weakness that increases with repetitive activity. Note: reporting should include the rate of repetition of stimulations and any significant incremental or decremental response.; Blink reflexes — to evaluate disease involving the 5th or 7th cranial nerves or brainstem. Note: recordings should be made bilaterally with both ipsilateral and contralateral stimulation.; Frequency: Two tests per year are appropriate per diagnosis for carpal tunnel (unilateral and bilateral), radiculopathy, mononeuropathy, polyneuropathy, myopathy, and neuromuscular junction disorders.; Frequency: Three tests per year are appropriate per diagnosis for motor neuronopathy and plexopathy.; Frequency exceptions allowing testing beyond the annual limits based on physician review: (1) evaluation by more than one EDX physician (e.g., second opinion) in a given year; (2) inconclusive diagnosis; (3) rapidly evolving disease that initial EDX testing may not show abnormality (e.g., early Guillain-Barre syndrome); (4) fluctuating disease course with variable response to treatment; (5) unexpected or changed course of disease (e.g., failure to improve after surgery for radiculopathy); (6) recovery from injury (monitor recovery, prognosticate, determine timing of surgical intervention, e.g., traumatic nerve injury); (7) new set of symptoms (e.g., evaluation for a second diagnosis the same year).. Applies to 9 codes: 95907, 95908, 95909, 95910, 95911, 95912, 95913, 95933, 95937. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation should include relevant history and physical examination that establish the working diagnosis and need for EDX testing.; NCS and EMG performed by a physician trained in electrodiagnostic medicine, or by a resident/fellow with direct supervision by an EDX-trained physician, including real-time interpretation by the EDX-trained physician. Only physicians may perform any portion requiring needle insertion (EMG); technologists may perform NCS only.; NCS performed, reported, and interpreted with the associated needle EMG on-site and in real time in accordance with AMA CPT code requirements for these procedures.; A full EDX report must be submitted, including all EDX tests performed and data summary tables; forwarding the NCS waveforms is encouraged.; (Documentation requirements above exclude blink reflexes.). Policy exclusions and limitations: Aetna considers the Cadwell Sierra II System experimental, investigational, or unproven.; Aetna considers examination/NCS studies using automated devices experimental, investigational, or unproven, including: ADVANCE NCS/EMG System; Brevio NCS monitor; Cadwell Sierra; NC-stat DPNCheck; NC-stat monitor; Neural Scan - Axon II; VT3000; XLTEK Neuropath; and other automated devices.; Aetna considers the Medi-Dx 7000 and Neural-Scan experimental, investigational, or unproven.; Aetna considers F-wave (F-reflex) study for carpal tunnel syndrome experimental, investigational, or unproven.; Aetna considers NCS for diagnosis of organophosphorus pesticide exposure experimental, investigational, or unproven.; Aetna considers NCS for evaluation of COVID-19 associated neuromuscular disorders experimental, investigational, or unproven.; Aetna considers NCS for evaluation of Peyronie's disease experimental, investigational, or unproven.; Aetna considers NCS for screening for polyneuropathy of diabetes or end-stage renal disease experimental, investigational, or unproven.; Aetna considers NCS for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease experimental, investigational, or unproven.; Aetna considers phrenic nerve conduction study for evaluation of phrenic nerve function of a lung transplant candidate experimental, investigational, or unproven.; Aetna considers NCS experimental, investigational, or unproven for screening neuropathy when symptoms and physical findings are mild, primarily sensory, and with a known cause (DSP).; Aetna considers EDX testing experimental, investigational, or unproven when the disease-specific criteria are not met.; Needle EMG studies are considered experimental, investigational, or unproven when these criteria are not met.; Unless an approvable exception is documented for EMG, NCS is considered not medically necessary; unless an approvable exception is documented, NCS cannot be approved without an approvable EMG request, and NCS studies are considered experimental, investigational, or unproven when these criteria are not met.; Neuromuscular junction testing is considered experimental, investigational, or unproven for all other indications.; Blink reflexes are considered experimental, investigational, or unproven for all other indications. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Does Aetna require prior authorization for Nerve Conduction Studies?

Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. Documentation: Documentation should include relevant history and physical examination that establish the working diagnosis and need for EDX testing.; NCS and EMG performed by a physician trained in electrodiagnostic medicine, or by a resident/fellow with direct supervision by an EDX-trained physician, including real-time interpretation by the EDX-trained physician. Only physicians may perform any portion requiring needle insertion (EMG); technologists may perform NCS only.; NCS performed, reported, and interpreted with the associated needle EMG on-site and in real time in accordance with AMA CPT code requirements for these procedures.; A full EDX report must be submitted, including all EDX tests performed and data summary tables; forwarding the NCS waveforms is encouraged.; (Documentation requirements above exclude blink reflexes.).

What does Aetna exclude for Nerve Conduction Studies?

Policy exclusions and limitations: Aetna considers the Cadwell Sierra II System experimental, investigational, or unproven.; Aetna considers examination/NCS studies using automated devices experimental, investigational, or unproven, including: ADVANCE NCS/EMG System; Brevio NCS monitor; Cadwell Sierra; NC-stat DPNCheck; NC-stat monitor; Neural Scan - Axon II; VT3000; XLTEK Neuropath; and other automated devices.; Aetna considers the Medi-Dx 7000 and Neural-Scan experimental, investigational, or unproven.; Aetna considers F-wave (F-reflex) study for carpal tunnel syndrome experimental, investigational, or unproven.; Aetna considers NCS for diagnosis of organophosphorus pesticide exposure experimental, investigational, or unproven.; Aetna considers NCS for evaluation of COVID-19 associated neuromuscular disorders experimental, investigational, or unproven.; Aetna considers NCS for evaluation of Peyronie's disease experimental, investigational, or unproven.; Aetna considers NCS for screening for polyneuropathy of diabetes or end-stage renal disease experimental, investigational, or unproven.; Aetna considers NCS for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease experimental, investigational, or unproven.; Aetna considers phrenic nerve conduction study for evaluation of phrenic nerve function of a lung transplant candidate experimental, investigational, or unproven.; Aetna considers NCS experimental, investigational, or unproven for screening neuropathy when symptoms and physical findings are mild, primarily sensory, and with a known cause (DSP).; Aetna considers EDX testing experimental, investigational, or unproven when the disease-specific criteria are not met.; Needle EMG studies are considered experimental, investigational, or unproven when these criteria are not met.; Unless an approvable exception is documented for EMG, NCS is considered not medically necessary; unless an approvable exception is documented, NCS cannot be approved without an approvable EMG request, and NCS studies are considered experimental, investigational, or unproven when these criteria are not met.; Neuromuscular junction testing is considered experimental, investigational, or unproven for all other indications.; Blink reflexes are considered experimental, investigational, or unproven for all other indications. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Related

• All Aetna coverage policies
• Aetna prior-authorization requirements — which codes need PA, by CPT