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Local Coverage Determination (LCD)

Somatosensory Testing

L35906

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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
L35906
Original ICD-9 LCD ID
Not Applicable
LCD Title
Somatosensory Testing
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL35906
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 04/04/2024
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
05/17/2015

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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

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. 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 an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the
following CMS sources:
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:

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:

160.23 Sensory Nerve Conduction Threshold Tests (sNCTs)

CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 23:

10.1-10.1.7 ICD-9-CM Coding for Diagnostic Tests

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 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) 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 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.

The Medicare Physician Fee Schedule Database (MPFSDB) physician supervision indicator for CPT codes 95925, 92526, 95927 and 95938 have Level 21 for the technical component. Level 21 defined as: Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician. Procedure may also be performed by a PT with ABPTS certification without physician supervision.
Program Memorandum Transmittal B-01-28/Change Request 850 sets forth revised levels of physician supervision required for diagnostic tests payable under the Medicare Physician Fee Schedule. Effective July 1, 2001, certain codes in the range of CPT 95860-95937 were assigned new supervision levels (21, 22, 6a, 66, 77 or 77a). This implementation date would make it possible for physical therapists to acquire the certification required to perform these services without supervision. A physical therapist who is presently certified by the American Board of Physical Therapy Specialties can perform procedures assigned level of 21, 22, 66, 6a, 77, or 77a without supervision. These numeric levels assigned to the CPT codes are listed in the Medicare Physician Fee Schedule Database (MFSDB). Physical therapists who do not possess the ABPTS (American Board of Physical Therapy Specialties) certification by July 1, 2001, may continue to furnish those tests that require the certification if they have been furnishing such diagnostic tests prior to May 1, 2001.

Therefore, if authorized by state law Physical Therapists are allowed the technical portion of the test.

Nurse practitioners, clinical nurse specialists, and physician assistants are not defined as physicians under §1861(r) of the Act. Therefore, they may not function as supervisory physicians under the diagnostic tests benefit (§1861(s)(3) of the Act). However, when these practitioners personally perform diagnostic tests as provided under §1861(s)(2)(K) of the Act, §1861(s)(3) does not apply and they may perform diagnostic tests pursuant to State scope of practice laws and under the applicable State requirements for physician supervision or collaboration. (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: Section 80: Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests).

CMS Publication 100-08, Program Integrity Manual, Chapter 13, Section 5.1 outlines that <> "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. Training and expertise must have been acquired within the framework of an accredited residency and/or fellowship program in the applicable specialty/subspecialty. If this skill has been acquired as continuing medical education, the courses must be comprehensive, offered, sponsored or endorsed by an academic institution in the United States and/or by the applicable specialty/subspecialty society in the United States, and designated by the American Medical Association (AMA) or the American Osteopathic Association (AOA) as Category 1 Credit. Documentation of training must be available upon request.

It is expected that the training and experience would include:

  • existing knowledge of the anatomic structures and neurophysiologic events underlying the generation of evoked potentials;
  • the influences of stimulus parameters and other experimental variables on the responses that are recorded;
  • relevant normative data and statistics; and
  • the clinical significance and pathologic correlates of dysfunctional neural pathways demonstrated by evoked potential alterations.




It is anticipated only allopathic or osteopathic physicians will have the necessary training to meet these requirements.
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
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Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
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MAC Meeting Information URLs
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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:

N/A

 Group 1 Codes:

N/A

N/A

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

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

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Additional ICD-10 Information

General Information

Associated Information

Documentations Requirements
The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") 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

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). "Somatosensory Evoked Potentials: Clinical Uses". Chapter 5. Muscle Nerve 22: Supplement 8: S111-S118, 1999. Accessed August 2014 at AANEM.org website.

American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). “Position Statement - Recommended Policy for Electrodiagnostic Medicine”. Accessed August 2014 at AANEM.org website.
Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
04/04/2024 R15

R15

Revision Effective: 04/04/2024

Revision Explanation: Annual review, no changes made.

03/29/2024 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.
  • Other (Annual Review)
03/24/2023 R14

R14

Revision Effective: 03/24/2023

Revision Explanation: Annual review, no changes made.

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.
  • Other (Annual Review)
03/31/2022 R13

R13

Revision Effective: 03/31/2022

Revision Explanation: Annual review. Removed documentation requirements and utilization guidelines from the associated information section. These details are in the related billing and coding article.

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.
  • Other (Annual Review)
04/01/2021 R12

R12

Revision Effective: 04/01/2021

Revision Explanation: Annual review, no changes.

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.
  • Other (Annual review)
09/26/2019 R11

R11

Revision Effective: n/a

Revision Explanation: Annual review, no changes.

3-25-2020: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.
  • Other (Annual Review)
09/26/2019 R10

R10

Revision Effective: 09/26/2019 Revision Explanation: Converted to new policy template that no longer includes coding section based on CR 10901.

09/20/2019: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.
  • Revisions Due To Code Removal
10/01/2018 R9

Revision#:R9

Revision Effective: N/A

Revision Explanation: Annual review, no changes made

03-13-2019: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
  • Other (Annual Review)
10/01/2018 R8

Revision#:R8

Revision Effective: 10/01/2018

Revision Explanation: During annual ICD-10 update I63.8 was deleted and replaced with I63.81 and I63.89. New codes from annual update I67.850 and I67.858 were added to group 1.

09/19/2018: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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2017 R7

Revision#:R7
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

03/28/2018: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.
  • Other (Annual Review)
10/01/2017 R6

Revision#:R6
Revision Effective: 10/01/2017
Revision Explanation: During annual ICD-10 update M48.06 was deleted and replaced with M48.061 and M48.062.

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.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2016 R5 Revision#:R5
Revision Effective: N/A
Revision Explanation: Annual review no changes made.
  • Other (Annual review)
10/01/2016 R4 Revision#:R4
Revision Effective: 10/01/2016
Revision Explanation: During annual ICD-10 update I60.21, I60.22, M50.02, and S06.0X6A were deleted and replaced with I60.2 and M50.021-M50.023. there was no replacement code for S06.0X6A.
  • Revisions Due To ICD-10-CM Code Changes
10/01/2015 R3 Revision#:R3
Revision Effective: N/A
Revision Explanation: Annual review no changes made at this time.
  • Other (annual review)
10/01/2015 R2 Revision#:R2
Revision Effective: N/A
Revision Explanation: Accepted revenue code description changes
  • Other (Revenu Code description)
10/01/2015 R1 Revision#:R1
Revision Effective: 10/01/2015
Revision Explanation: Added notice period dates.
  • Provider Education/Guidance
N/A

Associated Documents

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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
03/29/2024 04/04/2024 - N/A Currently in Effect You are here
03/13/2023 03/24/2023 - 04/03/2024 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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