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 electromyography (EMG) MG results reflect not only on the integrity of the functioning 
connection between a nerve and its innervated muscle but also on the integrity of a muscle itself. The axon 
innervating a muscle is primarily responsible for the muscle's volitional contraction, survival, and trophic 
functions. Thus, interruption of the axon will alter the EMG. A few prime examples of neurologic conditions in 
which EMG is potentially helpful, although not an all-inclusive listing, are disc disease producing spinal nerve 
dysfunction, advanced nerve compression in peripheral lesions, Amyotrophic Lateral Sclerosis (ALS), and 
polyneuropathy, etc. After an acute neurogenic lesion, it is important to note that EMG changes may not appear 
for several days to weeks in the innervated muscles. 
 
Primary muscle diseases such as polymyositis will also alter a normal EMG pattern. Myotonic disorders may 
show a pattern of spontaneous repetitive discharges on needle exploration. 
 
Neurogenic disorders can be distinguishable from myopathic disorders by a carefully performed EMG. For 
example, both polymyositis and ALS (Amyotrophic Lateral Sclerosis) produce 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 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 A 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. 
 
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 scar 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 EMG - This is not the same as a conventional EMG and involves the use of a probe that is 
passed over the surface of the skin in order to measure electrical muscle activity. This method of EMG testing 
is considered investigational and is not a covered service. Surface and macro EMGs will be denied as not 
medically necessary. An exception may be made for the use of surface EMG when used for EMG studies of the 
anal or urethral sphincter when performed in accordance with LCD L34977 (Anorectal Manometry, Anal 
Electromyography, and Biofeedback Training for Perineal Muscles and Anorectal or Urethral Sphincters). See 
that document for further coverage and limitations. 
    multiple uses of EMG in the same patient at the same location of the same limb for the purpose of 
optimizing botulinum toxin injections 
 
Nerve Conduction Studies (NCS) 
 
The dichotomy into axonal and demyelinating neuropathies provides a practical means of correlating electrical 
abnormalities with major pathophysiologic changes in the nerve. Electrical studies can be of help in 
localization of an abnormality and in distinguishing one variety of neuropathy from another: for example, 
diffuse vs. multifocal; axonal vs. demyelinating. Such distinction has diagnostic value. Specific classification 
of nerve injuries into neuropraxia and axonotmesis can be made on the basis of conduction studies and 
electromyography. Such classification has a bearing on prognosis and treatment. 
 
   1. Focal neuropathies or compressive lesions such as carpal tunnel syndrome, ulnar neuropathies or root 
lesions, for localization 
   2. Traumatic nerve lesions, for diagnosis and prognosis 
   3. Diagnosis or confirmation of suspected generalized neuropathies, such as diabetic, uremic, metabolic or 
immune 
   4. Repetitive nerve stimulation in diagnosis of neuromuscular junction disorders such as myasthenia gravis, 
myasthenic syndrome 
   5. There may be other instances, not detailed here, where NCS may be of use. Not all possible or potential 
indications are addressed here 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Nerve Conduction Studies 
and Electromyography (L35081). 
 
The rules say that an inpatient admission is generally appropriate when the admitting physician expects the 
patient to need hospital care that crosses at least two midnights. The expectation should be based on such 
complex medical factors as medical history, the severity of signs and symptoms, current medical needs, and 
medical risk. The factors must be documented in the medical record.  
 If an unforeseen event, such as a patient's death or transfer, results in a shorter stay, the patient may be 
considered to be treated as an inpatient. An inpatient admission for a surgical procedure listed by Medicare as 
inpatient only is generally appropriate, regardless of the length of stay. An inpatient admission may be 
appropriate if the admitting physician expects a patient to require hospital care for only a limited period of 
time. The decision to admit as an inpatient must be based on the clinical judgment of the physician and must be 
supported by the medical record. You can find this rule at 42 CFR Section 412.3. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
The rules say that providers/suppliers must report services correctly. Procedures should be reported with the 
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in 
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual 
for Medicare Services, Chapter I(A). 
 
The rules say that the Physician Fee Schedule Status Indicator I means that this code is not valid for Medicare 
purposes. Medicare uses another code for reporting of, and payment for, these services. You can find this 
information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-04, 
Medicare Claims Processing Manual, Chapter 23, 30.2.2. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.