Latest Review Date: June 2024

Category: Medicine                                                               

POLICY:

Paraspinal surface electromyography (SEMG) is considered investigational as a technique to diagnose or monitor back pain.

See Policy #228 for Neuromuscular and Electrodiagnostic: Nerve Conduction Studies and Electromyography Studies

DESCRIPTION OF PROCEDURE OR SERVICE:

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.  Additionally, this procedure has been studied as a technique to evaluate abnormal patterns of electrical activity in the paraspinal muscles in individuals with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders.

Back Pain

Back pain is a common condition that affects most individuals at some point in their lives. Identifying the pathogenesis of back pain is a challenging, in part due to the complex anatomy of the back, which includes vertebrae, intervertebral discs, facet joints, spinal nerve roots, and numerous muscles. Back pain may be related to osteoarthritis, disc disease, subluxation, or muscular pathologies, such as muscle strain or spasm. Moreover, due to referred pain patterns, the location of the pain may not be anatomically related to the pathogenesis of the pain. For example, buttock or leg pain may be related to pathology in the spine. In addition to the diagnostic challenges of back pain is the natural history of acute back pain.

Diagnosis

Aside from the physical exam, diagnostic testing includes imaging technologies, such as magnetic resonance imaging (MRI), designed to identify pathology (e.g., bulging discs), or tests such as discography to localize the abnormality by reproducing the pain syndrome. However, these tests lack specificity, and must be carefully interpreted in the context of the clinical picture.  For example, magnetic resonance imaging identifies 5% of asymptomatic individuals as having bulging discs.  However, the presence of a bulging disc may only be clinically significant if correlated with other symptoms.  Assessment of the musculature may focus on range of motion or strength exercises.

In contrast to anatomic imaging, surface electromyography (SEMG), which records the summation of muscle activity from groups of muscles, has been investigated as a technique to evaluate the physiological functioning of the back. A noninvasive procedure, SEMG differs from needle electromyography, an invasive procedure in which the electrical activity of individual muscles is recorded. Paraspinal SEMG has been explored to evaluate abnormal patterns of electrical activity in the paraspinal muscles in individuals with back pain symptoms such as spasm, tenderness, limited range of motion, or postural disorders. The technique is performed using a single 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 is assessed by computer analysis of the frequency spectrum (i.e., spectral analysis), amplitude, or root mean square of the electrical action potentials. In particular, a spectral analysis that focuses on the median frequency has been used to assess paraspinal muscle fatigue during isometric endurance exercises.  Paraspinal SEMG has been researched as a technique to establish the etiology of back pain and has been used to monitor the response to therapy and establish physical activity limits, such as assessing capacity to lift heavy objects or ability to return to work.

Paraspinal SEMG is an office-based procedure. 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 (LBP)
• Evaluation of exacerbation of chronic LBP
• Evaluation of pain management treatment techniques

Treatment

Most cases of acute LBP resolve with conservative therapy (e.g., physical therapy) while continuing normal activities within limits permitted by the pain. Therefore, initial imaging or other diagnostic testing is generally not recommended unless “red flag” warning signs are present or the pain persists for more than four to six weeks. Red flag findings include significant trauma, history of cancer, unrelenting night pain, fevers or chills, and progressive motor or sensory deficits.

KEY POINTS:

The most recent literature review was updated through April 10, 2024.

Summary of Evidence

For individuals who have back pain who receive paraspinal surface electromyography (SEMG) for evaluation and monitoring, the evidence includes several nonrandomized studies on using findings to classify back pain. The relevant outcomes are test accuracy and validity, symptoms, functional outcomes, quality of life, and resource utilization. There have been no studies directly comparing SEMG with other noninvasive techniques for evaluating back pain, and standard criteria for normal and abnormal SEMG measurements have not been determined. SEMG has been proposed as a noninvasive technique providing objective measurements that would inform treatment decisions in individuals with back pain. While the studies have shown that SEMG results have detected different pathologies in individuals with back pain, none of the studies reported health outcomes. There are also no data on the impact of SEMG for managing back pain. The evidence is insufficient to determine that the technology results in the net health outcomes.

Practice Guidelines and Position Statements

American College of Occupational and Environmental Medicine

In 2019, the guideline from the American College of Occupational and Environmental Medicine on diagnostic tests for low back disorders does not recommend surface electromyography as a technique for diagnosing low back disorders, based on insufficient evidence of efficacy.

North American Spine Society and American Academy of Pain Medicine

In 2020, The North American Spine Society with input from the American Academy of Pain Medicine issued a guideline on the diagnosis and treatment of low back pain. When discussing the diagnostic accuracy of non-imaging tests, the guideline lacks any statement on surface electromyography.

U.S. Preventive Services Task Force Recommendations

Not applicable.

KEY WORDS:

EMG, Surface, Paraspinal, Paraspinal Surface EMG, Surface EMG, Paraspinal, low back pain, low back disorders, SEMG, High-Density sEMG, (HD-sEMG)

APPROVED BY GOVERNING BODIES:

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. Examples include the CMAP Pro (Medical Technologies) and Model 9200 EMG System (Myotronics-Noromed).

Several FDA approved devices combine SEMG along the spine with other types of monitors. For example, in 2007, the Insight Discovery (Fasstech) was cleared for marketing through the 510(k) process. The device contains six sensor types, one of which is for SEMG. The indications include measuring bilateral differences in SEMG along the spine and measuring SEMG along the spine during functional tasks. (Earlier Insight models had fewer sensors.) FDA product code: IKN.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply.  Refer to member’s benefit plan. 

CURRENT CODING: 

CPT Codes:                 

There is no specific CPT code, but may be reported using the codes below.  Some plans have reported that this technology has been billed using CPT code 95860-95872 and 95885-95887, which is an incorrect code range that addresses the use of needle, not surface EMG.

HCPCS:        

REFERENCES:

1. Bittman B, Cram JR. Surface electromyography: an electrophysiological alternative in pain management. Paper presented at: Presented at the American Pain Society; Oct 22-25 1992; San Diego, CA.
2. Cram JR, Lloyd J and Cahn TS. The reliability of EMG muscle scanning. Int J Psychosom 1994; 41(1-4):41-5.
3. De Luca CJ. Use of the surface EMG signal for performance evaluation of back muscles. Muscle Nerve 1993; 16(2):210-216.
4. du Rose A, Breen A. Relationships between Paraspinal Muscle Activity and Lumbar Inter-Vertebral Range of Motion. Healthcare (Basel). Jan 05 2016; 4(1).
5. 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. Aug 1988; 88(8):991-7.
6. 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):920-8.
7. Hegmann KT, Travis R, Belcourt RM, et al. Diagnostic Tests for Low Back Disorders. J Occup Environ Med. Apr 2019; 61(4): e155-e168.
8. 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.
9. Hu Y, Siu SH, Mak JN, et al. Lumbar muscle electromyographic dynamic topography during flexion-extension. J Electromyelogram Kinesiol. Apr 2010; 20(2):246-255.
10. 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. Mar 2005; 14(2):175-84.
11. Hung CC, Shen TW, Liang CC, et al. Using surface electromyography (SEMG) to classify low back pain based on lifting capacity evaluation with principal component analysis neural network method. Conf Proc IEEE Eng Med Biol Soc. 2014; 2014:18-21.
12. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
13. 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 2012; 22(14):413-26.
14. Kienbacher T, Fehrmann E, Habenicht R, et al. Age and gender related neuromuscular pattern during trunk flexion-extension in chronic low back pain patients. J Neuroeng Rehabil. Feb 19 2016; 13:16.
15. Knezevic NN, Candido KD, Vlaeyen JWS, et al. Low back pain. Lancet. Jul 03 2021; 398(10294): 78-92.
16. Kreiner DS, Matz P, Bono CM, et al. Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain. Spine J. Jul 2020; 20(7): 998-1024.
17. 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 Pain. Apr 2013; 29(4):334-40.
18. Peach JP and McGill SM. Classification of low back pain with the use of spectral electromyogram parameters. Spine (Phila Pa 1976). May 15 1998; 23(10): 1117-23.
19. Roy SH and Oddsson LI. Classification of paraspinal muscle impairments by surface electromyography. Phys Ther. Aug 1998; 78(8):838-51.
20. Schabrun SM, Elgueta-Cancino EL, Hodges PW. Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain. Spine (Phila Pa 1976). Aug 1 2017; 42(15):1172-1178.
21. 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. Spin (Phila Pa 1976). April 15 2012; 37(8):E486-95.
22. Van Damme B, Stevens V, Perneel C, et al. A surface electromyography based objective method to identify patients with nonspecific chronic low back pain, presenting flexion related movement control impairment. J Electromyelogram Kinesiol. Dec 2014; 24(6):954-964.

POLICY HISTORY:

Medical Policy Group, July 2009 (3)

Medical Policy Administration Committee, August 2009

Available for comment August 10-September 23, 2009

Medical Policy Group, August 2010 (1): Description updated and no change in policy statement

Medical Policy Group, November 2011 (1): Update to Key Points; no change in policy statement

Medical Policy Group, December 2011 (3): Added statement for new 2012 Codes – 95885, 95886, 95887

Medical Policy Panel, November 2012

Medical Policy Group, November 2012 (2): No changes to policy statement.  Key Points and References updated. 

Medical Policy Group, December 2012 (3): 2013 Coding Updates: Verbiage change to Code 96004-added “or other qualified health care professional”.

Medical Policy Panel, September 2013

Medical Policy Group, October 2013 (2): No change to policy.  ACOEM statement updated with 2011 change. 

Medical Policy Panel, September 2014

Medical Policy Group, September 2014 (3): 2014 Updates to Key Points & References; no change in policy statement

Medical Policy Panel, September 2015

Medical Policy Group, September 2015 (6): Updates to Key Points and References; no change to policy statement.

Medical Policy Panel, June 2017

Medical Policy Group, June 2017 (6): Updates to Key Points, Practice Guidelines, and References; no change to policy statement.

Medical Policy Panel, June 2018

Medical Policy Group, June 2018 (6): Updates to Key Points and References.

Medical Policy Panel, June 2019

Medical Policy Group, June 2019 (3):2019 Updates to Key Points, References and Key Words: added: low back pain, low back disorder and SEMG. No changes to policy statement or intent.

Medical Policy Panel, October 2020

Medical Policy Group, November 2020 (3): Updates to Description, Key Points, Practice Guidelines and Position Statements, and References. No changes to policy statement or intent.

Medical Policy Panel, June 2021

Medical Policy Group, July 2021 (3): 2021 Updates to Key Points and Approved By Governing Bodies. Policy statement updated to remove “not medically necessary,” no other changes to policy statement or intent.

Medical Policy Panel, June 2022

Medical Policy Group, June 2022 (3): 2022 Updates to Key Points. No changes to policy statement or intent.

Medical Policy Panel, June 2023

Medical Policy Group, July 2023 (3): 2023 Updates to Key Points, Practice Guidelines and Position Statements, Benefit Applications, and References. Key Words added: High-Density sEMG, (HD-sEMG). No changes to policy statement or intent.

Medical Policy Panel, June 2024

Medical Policy Group, June 2024 (3): Updates to Description, Key Points, and References. No change to policy statement or intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.