L29280-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Somatosensory Testing (L29280)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29280

LCD Title Somatosensory Testing

Contractor's Determination Number 95925

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009 Original Determination Ending Date

Revision Effective Date

For services performed on or after 01/01/2012 Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

Short-latency somatosensory evoked potentials (SEPs) represent early electrophysiologic responses of the somatosensory pathways to stimulation. Somatosensory testing involves the application of multiple brief electrical stimuli over peripheral nerves (e.g., the median, peroneal, and tibial nerves) and recording the evoked potentials over proximal portions of the nerves stimulated, the plexus, spine and/or scalp. These readings are then

averaged by a computer and can be traced and recorded in the form of waveforms. A physician trained in interpreting clinical evoked potential studies then interprets these waveforms. The waveforms obtained should be described and the peak latencies, interpeak intervals (when appropriate), and amplitudes of the significant components detailed. The nerves most commonly stimulated are the median nerve at the wrist for testing in the upper extremity, and the common peroneal nerve (CPN) at the knee and the posterior tibial nerve at the ankle for the lower extremity.

Medicare will consider the use of short-latency somatosensory evoked potentials to be medically reasonable and necessary to assist in the diagnosis of certain neuropathologic states (as described below) in order to provide information for treatment and for intraoperative testing during spinal surgeries in which there is risk of additional nerve or spinal cord injury.

SEPs are used to evaluate the more proximal segments of nerves and the integrity of the central somatosensory pathways when slowing of conduction through the brain and/or brainstem, spinal cord, and/or peripheral nerves is suspected. This would include conditions such as multiple sclerosis, cervical spondylosis with myelopathy, coma, spinal cord trauma, hereditary and idiopathic peripheral neuropathies, inflammatory and toxic neuropathies, myoclonus, Friedreich’s ataxia, syringomyelia, spinal cord tumors, spinal stenosis and other conditions where there is spinal cord compression.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

95925 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER LIMBS

95926 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN LOWER LIMBS

95927 SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN THE TRUNK OR HEAD

SHORT-LATENCY SOMATOSENSORY EVOKED POTENTIAL STUDY, STIMULATION OF ANY/ALL PERIPHERAL 95938 NERVES OR SKIN SITES, RECORDING FROM THE CENTRAL NERVOUS SYSTEM; IN UPPER AND LOWERLIMBS

ICD-9 Codes that Support Medical Necessity

192.2 MALIGNANT NEOPLASM OF SPINAL CORD

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

225.3 BENIGN NEOPLASM OF SPINAL CORD

237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD

250.61 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED

250.62 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED

250.63 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

333.2 MYOCLONUS

334.1 FRIEDREICH'S ATAXIA

334.2 HEREDITARY SPASTIC PARAPLEGIA

336.0 SYRINGOMYELIA AND SYRINGOBULBIA

336.9 UNSPECIFIED DISEASE OF SPINAL CORD

340 MULTIPLE SCLEROSIS

356.0 - 356.9 HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 - 357.9 ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES

721.1 CERVICAL SPONDYLOSIS WITH MYELOPATHY

723.0 SPINAL STENOSIS IN CERVICAL REGION

724.2 SPINAL STENOSIS, LUMBAR REGION, WITHOUT NEUROGENIC CLAUDICATION

724.3 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

780.01 COMA

806.00 - 806.09 CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.10 - 806.19 OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.20 - 806.29 CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.30 - 806.39 OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY

806.4 CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

806.5 OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation maintained by the performing physician must clearly indicate the medical necessity of the service being billed. There should be evidence in the medical record that the test results were noted and influenced or contributed to the patient’s course of treatment. In addition, documentation that the service was performed must be included in the patient’s medical record. This documentation should include a hard copy computer generated recording of the test results along with the physician’s interpretation. The physician’s SEP report should note which nerves were tested, latencies at various testing points, and an evaluation of whether the resulting values are normal or abnormal. This information is normally found in the office/progress notes, hospital records, and/or procedure notes.

If the provider of somatosensory testing is other than the ordering/referring physician/nonphysician practitioner, the provider of the service must maintain a copy of the test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies.

Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of the policy.

SEP studies are covered when performed by providers of neurology services or other providers who have specialized training and expertise in performing and interpreting this test. Such training should include adequate educational experience in the following:

• The influences of stimulus parameters and other experimental variables on the responses that are recorded.

• Existing knowledge of the anatomic structures and neurophysiologic events underlying the generation of evoked potentials.

• The clinical significance and pathologic correlates of dysfunctional neural pathways demonstrated by evoked potentials alterations.

• Relevant normative data and statistics.

Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty. If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered or sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) as Category 1 Credit.

Appendices

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

SEP studies are appropriate only when a detailed clinical history and neurologic examination and imaging studies, and EMG/Nerve Conduction studies have failed to provide adequate information for a specific treatment plan.

Sources of Information and Basis for Decision

American Association of Electrodiagnostic Medicine (AAEM). (2006). Recommended policy for electrodiagnostic medicine. Retrieved December 5, 2006 from http://www.aanem.org/practiceissues/recPolicy/recommended_policy_1.cfm

American Association of Neuromuscular & Electrodiagnostic Medicine. (2006). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve 33:436-439.

Goetz, C.G. (2003). Textbook of Clinical Neurology, 2nd ed. Chicago: Saunders.

Legatt, A. (2006). Somatosensory Evoked Potentials: General Principles. Retrieved December 4, 2006, from http://www.emedicine.com/neuro/topic640.htm

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:01/01/2012 Revised Effective Date: 01/01/2012

LCR B2012-015

December 2011 Connection

Explanation of Revision: Annual 2012 HCPCS Update. Added CPT code 95938. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Added ICD-9-CM code 274.03. Revised descriptor for ICD-9-CM code 274.02. The effective date of this revision is based on date of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL

December 2008 Update

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29280) replaces LCD L6507 as the policy in notice. This document (L29280) is effective on 02/02/2009.

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

Reason for Change