Appeal type: unknown
Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
  
  The rules say that neurogenic disorders can be distinguishable from myopathic disorders by a carefully 
performed Electromyography (EMG). For example, both polymyositis and ALS produce manifest weakness. 
The former carries a very different prognosis and treatment than the latter. An EMG is very valuable in making 
this distinction. Similarly, classification of nerve trauma into axonal vs. demyelinating categories, with 
corresponding differences in prognoses, are possible with EMG. Below is a list of common disorders where an 
EMG, in tandem with a properly conducted NCS, will be helpful in diagnosis: 
1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions. 
2. Radiculopathy - cervical, lumbosacral. 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary. 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies. 
5. Plexopathy - idiopathic, trauma, infiltration. 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here. 
7. At times, immediately prior to botulinum toxin injection, for localization. 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or 
chemodenervation. 
There may be other instances, not detailed here, where EMG may be of use. 
 
Use of EMG with Botulinum Toxin Injection 
EMG may be used to optimize the anatomic location of botulinum toxin injection. It is expected there will be 
one study performed per anatomic location of injection, if needed. 
 
Limitations: 
 
Screening testing for polyneuropathy of diabetes or endstage renal disease (ESRD) is NOT covered. 
Testing for the sole purpose of monitoring disease intensity or treatment efficacy in these two conditions is also 
not covered.  
 
Current Perception Threshold/Sensory Nerve Conduction Threshold Test (sNCT)  is not covered by 
Medicare.  
 
Electromyography 
The necessity and reasonableness of the following uses of EMG studies have not been established: 
 exclusive testing of intrinsic foot muscles in the diagnosis of proximal lesions 
 definitive diagnostic conclusions based on paraspinal EMG in regions bearing scars of past surgeries 
(e.g., previous laminectomies) 
 pattern-setting limited limb muscle examinations, without paraspinal muscle testing for a diagnosis of 
radiculopathy 
 EMG testing shortly after trauma, before EMG abnormalities would have reasonably had time to 
develop 
 surface and macro EMGs 
 multiple uses of EMG in the same patient at the same location of the same limb for the purpose of 
optimizing botulinum toxin injections. 
You can find this in the Local Coverage Determination (LCD): Nerve Conduction Studies and 
Electromyography (L35048). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.