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Local Coverage Determination (LCD)

Somatosensory Testing

L34433

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34433
Original ICD-9 LCD ID
Not Applicable
LCD Title
Somatosensory Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL34433
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 09/12/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
04/13/2017
Notice Period End Date
05/28/2017

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

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)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

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

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Analysis of Evidence (Rationale for Determination)

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Proposed Process Information

Synopsis of Changes
Changes Fields Changed
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Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

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 Group 1 Codes:

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Additional ICD-10 Information

General Information

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.
Sources of Information
N/A
Bibliography

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

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
09/12/2024 R15

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.
  • Provider Education/Guidance
07/27/2023 R14

Under Bibliography corrected broken hyperlink for source #1. Formatting, punctuation and typographical errors were corrected throughout the LCD.
  • Provider Education/Guidance
06/17/2021 R13

Under CMS National Coverage Policy updated regulation headings and description for regulation Title XVIII of the Social Security Act §1862(a)(14). Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were defined and inserted where appropriate throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
10/24/2019 R12

This LCD is being revised in order to adhere to CMS requirements per chapter 13, section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and placed in the related Billing and Coding: Somatosensory Testing A56769 article. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Provider Education/Guidance
08/01/2019 R11

Under CMS National Coverage Policy removed the verbiage “Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:” All coding located in the Coding Information section has been moved into the related Billing and Coding: Somatosensory Testing A56769 article and removed from the LCD.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
04/12/2018 R10

Under CMS National Coverage Policy deleted the second and third sentences “NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review a NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act”.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 
  • Provider Education/Guidance
02/26/2018 R9 The Jurisdiction "J" Part B Contracts for Alabama (10112), Georgia (10212) and Tennessee (10312) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 02/25/18. Effective 02/26/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part B contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/29/2018 R8 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
10/01/2017 R7

Under ICD-10 Codes That Support Medical Necessity deleted ICD-10 code M48.06 and added M48.061 and M48.062. This revision is due to the 2017 Annual ICD-10 Updates.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy. 

 
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
05/29/2017 R6 No revisions were made as no comments were received from the provider community.
  • Provider Education/Guidance
10/01/2016 R5 Under ICD-10 Codes That Support Medical Necessity: Group 1 added ICD-10 codes M50.020, M50.021, M50.022, M50.023, M50.121, M50.122, M50.123, R40.2410, R40.2411, R40.2412, R40.2413, R40.2414, R40.2420, R40.2421, R40.2422, R40.2423, R40.2424, R40.2430, R40.2431, R40.2432, R40.2433, R40.2434, R40.2440, R40.2441, R40.2442, R40.2443, and R40.2444. This revision is due to the Annual ICD-10 Code Update.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
06/09/2016 R4 Under CMS National Coverage Policy Title XVIII of the Social Security Act §1861(r) changed the word “practive” to “practice” and added verbiage “such function or action” to the end of the sentence. Verbiage was added to the beginning of Title XVIII of the Social Security Act §1861(s)(3) to read “The term “medical and other health services means any of the following items or services:” Subsection (i) was added to Title XVIII of the Social Security Act §1861(s)(2)(K) and verbiage was revised to read “services furnished under the supervision of a physician”. The word “Medicare” and "Manual" were added to “National Coverage Determinations, Chapter 1, Part 2, §160.23” to CMS Internet –Only Manual, Pub 100-03. Under Coverage Indications, Limitations and/or Medical Necessity - Abstract added an “s” to each word nerve in the second paragraph. Under Coverage Indications, Limitations and/or Medical Necessity – Other comments added “Comprehensive Outpatient Rehabilitation Facility and placed CORFs in parenthesis in second paragraph. Throughout the LCD capitalization, spelling and punctuation were corrected.
  • Provider Education/Guidance
  • Typographical Error
10/01/2015 R3 Per CMS Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 13, §13.1.3 LCDs consist of only “reasonable and necessary” information. All bill type and revenue codes have been removed.
  • Other (Bill type and/or revenue code removal)
10/01/2015 R2 Under CMS National Coverage Policy removed the citation for 100-04, Chapter 23 sections 10.1 through 10.1.7 as these citations are no longer valid, added reference to Publication 100-04, Chapter 23, Sections 10.4, 10.5, 10.6 and 20, and added reference to SSA 1862(a)(14).
Under Coverage Indications, Limitations and/or Medical Necessity under the Other Comments section removed the citation to 1861(s)(2), 1862(a)(14), 42 CFR and 58 CFR.
Under Revenue Codes (in the paragraph) removed reference to the FISS CPT/HCPCS file as it is not a maintainable system.
Under Associated Information in the documentations requirements corrected the second paragraph to read “Coverage Indications, limitations and/or Medical Necessity”.
Under Sources of Information and Basis for Decision corrected the citation to AMA formatting and to meet 508 compliance.
  • Provider Education/Guidance
  • Typographical Error
  • Other (Annual validation)
10/01/2015 R1 Under ICD-10 codes that support Medical Necessity removed ICD-10 codes M47.17 and M47.18 from the ICD-10 array as the codes were deleted 1/1/2014.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
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Associated Documents

Attachments
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Related National Coverage Documents
NCDs
160.23 - Sensory Nerve Conduction Threshold Tests (sNCTs)
Public Versions
Updated On Effective Dates Status
09/06/2024 09/12/2024 - N/A Currently in Effect You are here
07/18/2023 07/27/2023 - 09/11/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • Somatosensory

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