LCD L34624

Coverage Guidance

Title XVIII of the Social Security Act (SSA):

Section 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.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Code of Federal Regulations:

42 CFR, Section 410.32, indicates that 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) who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter).

CMS Publications:

CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests

CMS Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2: Section 160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23 - Fee Schedule Administration and Coding Requirements: Section 10 - Reporting ICD Diagnosis and Procedure Codes

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 provider trained in interpreting clinical evoked potential studies analyzes the waveforms. The waveforms obtained should be described by nerve 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 nerve 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 EMG can identify these types of lesions and no added information is obtained from SEP. This local coverage determination discusses medically necessary indications and limitations for SEPs.

Indications:

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) to provide information for treatment decisions and 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 and 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.

Summary of Evidence

N/A

Analysis of Evidence

N/A

Associated Information

Documentations Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD and associated Billing and Coding Article. 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 provider 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 provider’s interpretation. The provider’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

Kraft GH, Aminoff MJ, Baran EM, Litchy WJ, Stolov WC. Somatosensory evoked potentials: clinical uses. AAEM Somatosensory Evoked Potentials Subcommittee. American Association of Electrodiagnostic Medicine. Muscle Nerve. 1998;21(2):252-258. doi:10.1002/(sici)1097-4598(199802)21:2<252::aid-mus17>3.0.co;2-3

Recommended policy for electrodiagnostic medicine. AANEM. Accessed July 21, 2025. https://www.aanem.org/clinical-practice-resources/position-statements/position-statement/recommended-policy-for-electrodiagnostic-medicine