Archived Policies - Medicine


Surface Scanning Electromyography (EMG) (SEMG), Paraspinal Surface EMG, and Spinoscopy

Number:MED205.006

Effective Date:04-01-2015

End Date:09-30-2016

Coverage:

The following noninvasive electromyography (EMG) tests are considered experimental, investigational and/or unproven as techniques to evaluate, diagnose or monitor neck/back pain or any other neuromusculoskeletal condition:

Surface EMG (SEMG) or surface scanning EMG, OR

Paraspinal SEMG or paraspinal EMG, OR

Spinoscopy.

Description:

Surface electromyography (SEMG), a noninvasive procedure that records the summation of muscle electrical activity, has been investigated as a technique to evaluate the physiological functioning of the back. In contrast to anatomic imaging, SEMG records the summation of muscle activity from groups of muscles. SEMG, a noninvasive procedure, is contrasted with needle EMG, an invasive procedure, in which the electrical activity of individual muscles is recorded.

Paraspinal SEMG, also referred to as paraspinal EMG scanning, has been explored as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in patients with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders. The technique is performed using one or an array of electrodes placed on the skin surface, with recordings made at rest, in various positions, or after a series of exercises. Recordings can also be made by using a handheld device, which is applied to the skin at different sites. Electrical activity can be assessed by computer analysis of the frequency spectrum (i.e., spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, spectral analysis focusing on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises. Paraspinal SEMG is an office-based procedure that may be most commonly used by physiatrists or chiropractors. SEMG devices approved by the U.S. Food and Drug Administration (FDA) include those that use a single electrode or a fixed array of multiple surface electrodes. The following clinical applications of the paraspinal SEMG have been proposed:

Clarification of a diagnosis (i.e., muscle, joint, or disc disease),

Select a course of medical therapy,

Select a type of physical therapy,

Pre-operative evaluation,

Postoperative rehabilitation,

Follow-up of acute low back pain,

Evaluation of exacerbation of chronic low back pain, and

Evaluation of pain management treatment techniques.

Spinoscopy (Spinoscope®, Spinex Corp.) consists of SEMG with associated video-recordings that records vertebral movement and the corresponding muscular activity during movements of the back.

Rationale:

This policy was originally created in 1994 and was updated regularly with searches of the MEDLINE database through January 2015. Following is a summary of the key literature to date:

Surface electromyography (SEMG) has been used as a research tool to evaluate the performance of paraspinal muscles in patients with back pain and to further understand the etiology of low back pain. (1-4) Preliminary research has also been performed on which SEMG parameters best differentiate between patients with and without back pain. (5, 6) However, validation of its use as a clinical diagnostic technique involves a sequential 3-step procedure as follows:

Technical performance of a device is typically assessed by studies that compare test measurements with a criterion standard and those that compare results taken with the same device on different occasions (test-retest).

Diagnostic performance is evaluated by the ability of a test to accurately diagnose a clinical condition in comparison with the criterion standard. The sensitivity of a test is the ability to detect a disease when the condition is present (true positive), while specificity indicates the ability to detect patients who are suspected of disease but who do not have the condition (true negative). Evaluation of diagnostic performance, therefore, requires independent assessment by the 2 methods in a population of patients who are suspected of disease but who do not all have the disease.

Evidence related to improvement of clinical outcomes with use of this testing assesses the data linking use of a test to changes in health outcomes (clinical utility). While in some cases, tests can be evaluated adequately using technical and diagnostic performance, when a test identifies a new or different group of patients with a disease; randomized trials are needed to demonstrate impact of the test on the net health outcome.

The following discussion focuses on these 3 steps as they apply to SEMG.

Technical Performance

Several studies using different SEMG devices have suggested that paraspinal SEMG, in general, is a reliable technique, based on coefficients of variation or test-retest studies. (1,7) No studies were identified that compared the performance of SEMG to a criterion standard reference test.

 

Diagnostic Performance

No articles that compare the results of SEMG (which tests groups of muscles) with needle electromyography (which tests individual muscles) for diagnosing any specific muscle pathology were identified in literature searches. However, the pathology of individual muscles (i.e., radiculopathy, neuropathy) may represent a different process than the pathology of muscle groups (i.e., muscle strain, spasm), and thus SEMG may be considered by its advocates as a unique test for which there is currently no criterion standard. Nevertheless, even if one accepts this premise, there are inadequate data to evaluate the diagnostic performance of SEMG. For example, no articles were identified in the published peer-reviewed literature that established definitions of normal or abnormal SEMG. In some instances, asymmetrical electrical activity may have been used to define abnormality; results may be compared with normative data. However, there was no published literature defining what degree of asymmetry would constitute abnormality or how a normative database was established. (8)

In the absence of a criterion standard diagnostic test, correlation with the clinical symptoms and physical exam is critical. De Luca published a series of studies investigating a type of SEMG called the Back Analysis System (BAS), consisting of surface electrodes and other components to measure the electrical activity of muscles during isometric exercises designed to produce muscle fatigue. (2) Using physical exam and clinical history as a criterion standard, the author found that the BAS was able to accurately identify control and back pain patients 84% and 91% of the time, respectively, with the values increasing to 100% in some populations of patients. (Accuracy is the sum of true positive and true negative results.) However, these studies were not designed as a clinical diagnostic tool per se but were intended to investigate the etiology of back pain and to investigate muscular fatigue patterns in patients with and without back pain.

Hu et al in Hong Kong published 2 articles on dynamic topography, an approach to analyzing SEMG findings. (9, 10) The studies had similar protocols. Both included low back pain patients and healthy controls; all participants underwent SEMG at study enrollment and then back pain patients participated in a rehabilitation program. The first study found different dynamic topography at baseline between healthy people and people with back pain, e.g., a more symmetric pattern in healthy controls. (9) After physical therapy, the dynamic topography images of back pain patients were more similar to the healthy controls on some of the parameters that were assessed. In the second study, following rehabilitation, back pain patients were classified as responders or nonresponders based on changes in back pain severity. (10) Some associations were found between baseline SEMG parameters and response to rehabilitation. SEMG was not repeated following the rehabilitation program, and thus it is not clear whether there are any significant associations between continued symptoms and SEMG abnormalities. Moreover, it is not clear how SEMG analysis would affect treatment decisions for low back pain patients.

Improvement of Clinical Outcomes

Several articles describe the use of SEMG as an aid in classifying low back pain. (11-13) Much of this research has focused on the use of spectral analysis to assess muscle fatigability rather than how information from SEMG could enhance patient management. While SEMG may be used to objectively document muscle spasm or other muscular abnormalities, it is unclear how such objective documentation would supplant or enhance clinical evaluation, or how this information would be used to alter the treatment plan. In part, the difficulty in clinical interpretation understands the extent to which the SEMG abnormalities are primary or secondary. In addition, as noted in the Background section, no specific workup is recommended for acute low back pain without warning signs.

There are no data regarding the impact of SEMG on the final health outcome. For example, SEMG has been proposed as a technique to differentiate muscle spasm from muscle contracture, with muscle spasm treated with relaxation therapy and contracture treated with stretching exercises. However, there are no data to validate that such treatment suggested by SEMG resulted in improved outcomes. (14, 15)

A literature review of spinal muscle evaluation in low back pain patients, published in 2007, indicated that the validity of SEMG remains controversial. (16) The authors note that although many studies show increased fatigability of the paraspinal muscles in patients with low back pain, it is not known whether these changes are causes or consequences of the low back pain. Also, the utility of SEMG is limited because of the inability to clearly define normal versus abnormal profiles due to factors such as a lack of normative data.

Summary:

There are inadequate data on the technical and diagnostic performance of paraspinal surface electromyography (SEMG) compared with a criterion standard reference test. Moreover, there is insufficient evidence regarding how findings from paraspinal SEMG impact patient management and/or how use of the test improves health outcomes. In addition, no new information found that would change the coverage position for spinoscopy. Therefore surface EMG (SEMG), paraspinal SEMG or spinoscopy for diagnosing and monitoring back pain remains experimental, investigational, and/or unproven.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

CPT codes 95860-95872 are not to be used to bill this technology as this code range addresses the use of needle, not surface electromyography (SEMG).

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

None

HCPCS Codes

S3900

ICD-9 Diagnosis Codes

Refer to the ICD-9-CM manual

ICD-9 Procedure Codes

Refer to the ICD-9-CM manual

ICD-10 Diagnosis Codes

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at http://www.cms.hhs.gov>.

References:

1. Cram JR, Lloyd J, Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom. 1994; 41(4-Jan):41-45.

2. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve. 1993; 16(2):210-216.

3. Jones SL, Hitt JR, Desarno MJ, et al. Individuals with non-specific low back pain in an active episode demonstrate temporally altered torque responses and direction-specific enhanced muscle activity following unexpected balance perturbations. Exp Brain Res. Sep 2012; 221(4):413-426. PMID 22875027

4. Sheeran L, Sparkes V, Caterson B, et al. Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain: classification analysis. Spine (Phila Pa 1976). Apr 15 2012; 37(8):E486-495. PMID 22024899

5. Hanada EY, Johnson M, Hubley-Kozey C. A comparison of trunk muscle activation amplitudes during gait in older adults with and without chronic low back pain. PM R. Oct 2011; 3(10):920-928. PMID 22024323

6. Neblett R, Brede E, Mayer TG, et al. What is the best surface EMG measure of lumbar flexion-relaxation for distinguishing chronic low back pain patients from pain-free controls? Clin J Pain. Apr 2013; 29(4):334-340. PMID 23328325

7. Ahern DK, Follick MJ, Council JR, et al. Reliability of lumbar paravertebral EMG assessment in chronic low back pain. Arch Phys Med Rehabil. 1986; 67(10):762-765.

8. Gentempo P, Kent C. Establishing medical necessity for paraspinal EMG scanning. Chiropractic: J Chiropractic Res Clin Invest. 1990; 3(1):22-25.

9. Hu Y, Siu SH, Make JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyogr Kinesiol. 2010; 20(2):246-255.

10. Hu Y, Kwok JW, Tse JY, et al. Time-varying surface electromyography topography as a prognostic tool for chronic low back pain rehabilitation. Spine J. Jun 1 2014; 14(6):1049-1056. PMID 24530438

11. Humphrey AR, Nargol AV, Jones AP, et al. The value of electromyography of the lumbar paraspinal muscles in discriminating between chronic-low-back-pain sufferers and normal subjects. Eur Spine J. 2005; 14(2):175-184.

12. Peach JP, McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine. 1998; 23(10):1117-1123.

13. Roy SH, Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther. 1998; 78(8):838-851.

14. Ellestad SM, Nagle RV, Boesler DR, et al. Electromyographic and skin resistance responses to osteopathic manipulative treatment for low-back pain. J Am Osteopath Assoc. 1988; 88(8):991-997.

15. Bittman B, Cram JR. Surface electromyography: an electrophysiologic alternative in pain management. Presented at the American Pain Society; 1992; Illinois.

16. Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine. 2007; 74(1):9-13.

17. American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. www.guideline.gov. Accessed June, 2014.

18. Paraspinal Surface Electromyography (EMG) to Evaluate and Monitor Back Pain. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2014 September) 2.01.35.

Policy History:

Date Reason
4/1/2015 Document updated with literature review. Coverage unchanged.
9/15/2012 Document updated with literature review. Coverage unchanged.
1/1/2010 Revised/Updated Entire Document, no change in experimental, investigational, and unproven coverage position.
5/15/2007 Revised/Updated Entire Document
10/1/2003 Codes Revised/Added/Deleted
8/15/2003 Revised/Updated Entire Document
1/1/1998 Revised/Updated Entire Document
5/1/1996 Revised/Updated Entire Document
1/1/1995 Revised/Updated Entire Document
4/1/1994 Revised/Updated Entire Document

Archived Document(s):

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