LCD L34433

Coverage Guidance

Title XVIII of the Social Security Act, §1861(r) states the term "physician" used in connection with the performance of any function or action means, a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action

Title XVIII of the Social Security Act, §1861(s)(2)(K)(i) addresses services furnished under the supervision of a physician

Title XVIII of the Social Security Act, §1861(s)(3) states the term "medical and other health services" means diagnostic X-ray tests (including tests under the supervision of a physician, furnished in a place of residence used as the patient's home)

Title XVIII of the Social Security Act, §1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1862(a)(14) excludes payment for services, which are other than physicians' services, certified nurse-midwife services, qualified psychologist services, and services of a certified registered nurse anesthetist, and which are furnished to an individual who is a patient of a hospital or critical access hospital by an entity other than the hospital or critical access hospital, unless the services are furnished under arrangements with the entity made by the hospital or critical access hospital

42 CFR §410.32 indicates diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, §160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)

Indications and Limitations of Coverage

Abstract:

Short-latency somatosensory evoked potentials (SEPs) represent electrophysiologic responses of the somatosensory pathways to stimulation. Somatosensory testing involves the application of a series of brief electrical stimuli over peripheral nerves (e.g., the median, peroneal, and tibial nerves) and recording the resulting evoked potentials over proximal portions of the nerves and central pathways which were stimulated, the plexus, spine and/or scalp. Action potentials recorded from these sites are averaged by a computer to improve signal clarity, and then displayed in standard formats on the computer’s screen as well as in printed form.

A physician trained in interpreting clinical evoked potential studies analyzes the waveforms. The waveforms obtained should be described by nerves being stimulated, the recording sites, peak latencies, interpeak intervals (when appropriate), and amplitudes of the significant components. The nerves most commonly stimulated are the median nerves at the wrist for testing in the upper extremity, and the posterior tibial nerve at the ankle or common peroneal nerve (CPN) at the knee for the lower extremity.

SEPs evaluate the entire somatosensory pathway from the site of stimulation up to the cerebral cortex. It is possible to distinguish between lesions located in the peripheral nerve, in the dorsal column spinal cord pathway, or higher centers in the brain up through the cortex. In general, there is no need for SEP in the diagnosis of most peripheral neuropathies, because the conventional nerve conduction studies or needle electromyography (EMG) can identify these types of lesions and no added information is obtained from SEP. This local coverage determination (LCD) discusses medically necessary indications and limitations for SEPs.

Indications:

Medicare will consider the use of short-latency SEPs 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 decisions and also for intraoperative electrophysiological monitoring during spinal surgeries, in which there is risk of additional nerve or spinal cord injury. However, it is not anticipated that such monitoring will be medically necessary for the typical cervical or lumbar root decompression procedures.

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

Limitations:

SEP studies are appropriate only when a detailed clinical history, neurologic examination and appropriate diagnostic tests such as imaging studies, electromyogram, and nerve conduction studies make a lesion (or lesions) of the central somatosensory pathways a likely and reasonable differential diagnostic possibility.

Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians; therefore, they may not function as supervisory physicians under the diagnostic tests benefit. However, when these practitioners personally perform diagnostic tests, as provided they may do so in pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration.

Reasonable and necessary services are ordered and/or furnished by qualified personnel. Provision of interpretation and/or supervision of these tests will be considered medically reasonable and necessary, only if performed by appropriately trained providers.

Other Comments:

Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes.

For outpatient settings other than Comprehensive Outpatient Rehabilitation Facilities (CORFs), references to "physicians" throughout this policy include nonphysicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such nonphysician practitioners, with certain exceptions, may certify, order and establish the plan of care as authorized by State law.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentation Requirements

Documentation must be legible, relevant and sufficient to justify the services billed. This documentation must be made available to the A/B MAC upon request.

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD (see Coverage Indications, Limitations and/or Medical Necessity). This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

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 or referring physician or 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.

Providers of interpretations, supervision and performance of the technical portions of the studies must be capable of demonstrating documented training and experience for post-payment audit.

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.

Bibliography

Recommended Policy for Electrodiagnostic Medicine. American Association of Neuromuscular & Electrodiagnostic Medicine. Published September 1997. Updated 2004. Accessed 8/6/24.