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12437 Results

Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side

Service Code
95852 (CPT) Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Electrodiagnostic Studies

Service Code
95860 (CPT) Needle electromyography; 1 extremity with or without related paraspinal areas
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95861 (CPT) Needle electromyography; 2 extremities with or without related paraspinal areas
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95863 (CPT) Needle electromyography; 3 extremities with or without related paraspinal areas
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95864 (CPT) Needle electromyography; 4 extremities with or without related paraspinal areas
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95867 (CPT) Needle electromyography; cranial nerve supplied muscle(s), unilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95868 (CPT) Needle electromyography; cranial nerve supplied muscles, bilateral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95869 (CPT) Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95870 (CPT) Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95872 (CPT) Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking and/or fiber density, any/all sites of each muscle studied
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95875 (CPT) Ischemic limb exercise test with serial specimen(s) acquisition for muscle(s) metabolite(s)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95885 (CPT) Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95886 (CPT) Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal lev
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95886 (CPT) Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal lev
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95907 (CPT) Nerve conduction studies; 1-2 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95908 (CPT) Nerve conduction studies; 3-4 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95909 (CPT) Nerve conduction studies; 5-6 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95910 (CPT) Nerve conduction studies; 7-8 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95911 (CPT) Nerve conduction studies; 9-10 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources

Electrodiagnostic Studies

Service Code
95912 (CPT) Nerve conduction studies; 11-12 studies
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

In diagnosing muscle and nerve disorders, providers often conduct 2 different tests a needle electromyogram (an EMG) and a nerve conduction study (NCS). Needle EMGs test the electrical activity of muscles, while NCSs test how fast and well a nerve sends these electrical signals. When functioning correctly, the nerves send electrical impulses to the muscles, which then respond in a particular way. When they do not respond as expected, providers conduct tests to determine the cause. Typically, needle EMGs and NCSs are conducted in tandem, providing a complete picture of the beneficiary’s condition. The electrodiagnostic (EDX) evaluation is an extension of the neuromuscular portion of the physical examination. EDX evaluations are performed by providers, almost exclusively neurologists or physiatrists. An EDX evaluation requires a detailed knowledge of a beneficiary’s disease. During an EDX evaluation, providers typically perform needle electromyography (EMG) and nerve conduction studies (NCSs). Electrodiagnostic studies may be rendered by a Licensed Physical Therapist if currently listed on the American Physical Therapy Association website as a Board Certified Clinical Electrophysiologic Certified Specialist per the American Board of Therapy Specialists

Authorization Guidelines

Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Limits

1 per day

Exclusions

  • a. Examinations using portable hand-held devices;
  • b. Using the studies as screening tests for polyneuropathy of diabetes or endstage renal disease in beneficiaries without clinical deficits is not indicated;
  • c. Using the studies for the sole purpose of monitoring disease intensity or treatment effectiveness for polyneuropathy of diabetes or end-stage renal disease;
  • d. EDX testing with automated, noninvasive nerve conduction testing devices is considered investigational and not medically necessary for all indications
  • e. Psychophysical measurements (current, vibration, thermal perceptions), even though they involve delivery of a stimulus, are not covered;
  • f. Current Perception Threshold and Sensory Nerve Conduction Threshold Test (sNCT) is investigational and not covered; or
  • g. Studies performed with devices designed only for “screening purposes” rather than diagnosis is not acceptable under this policy.

Additional Service Specifics

All codes with the exception of 95940 and 95941 may be performed inpatient, outpatient hospital, Independent Diagnostic Testing Facilities (IDTF) and office. 95940 and 95941 are limited to inpatient and outpatient hospital.

How to Submit

N/A - No authorization is required

Resources