Nerve Fiber Density Testing
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Defines reimbursement criteria and coding/billing guidance for epidermal nerve fiber density (ENFD) testing from skin biopsy for diagnosis of small-fiber neuropathy, and states non-reimbursement for other uses including sweat gland nerve fiber density.
01/12/2026 document updated with literature review; Reimbursement Information unchanged; References revised.
03/01/2024 reimbursement information revised for clarity; added code 88313; removed codes 88305 and 88314.
11/1/2022 New policy created.
Policy overview
This policy (Policy Number: CPCPLAB064) defines reimbursement criteria and coding/billing guidance for epidermal nerve fiber density (ENFD) testing from skin biopsy to diagnose small-fiber neuropathy. The policy summarizes medically reimbursable indications and explicit non-reimbursable uses (e.g., sweat gland nerve fiber density) and states that not all requirements apply to each product — plan documents govern coverage specifics and prevail in case of conflict. Evidence informing the policy includes Practice Parameters and guidelines from organizations such as the American Academy of Neurology (AAN), the European Federation of Neurological Societies (EFNS), and multiple peer-reviewed studies and reviews.
Subject: Nerve Fiber Density Testing (epidermal nerve fiber density from skin biopsy); Coverage stance: mixed; Status: CURRENT.
Coverage criteria (when ENFD testing is reimbursable)
Medically Reimbursable Indication for ENFD Testing
ENFD measurement from skin biopsy may be reimbursable when ALL of the following conditions are met:
ALL of the following
- An individual presents with symptoms of painful sensory neuropathy
- There is no history of a disorder known to predispose to painful neuropathy (e.g., diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy)
- Physical examination shows no evidence of findings consistent with large-fiber neuropathy, such as reduced or absent muscle-stretch reflexes or reduced proprioception and vibration sensation
- Electromyography and nerve-conduction studies are normal and show no evidence of large-fiber neuropathy
Not Reimbursable
Not reimbursable
ANY of the following
- Epidermal nerve fiber density measurement from a skin biopsy for situations not meeting the above criteria (i.e., all other situations)
- Measurement of sweat gland nerve fiber density
Code lists and coding notes
| No codes listed |
Providers must submit accurate documentation of services and submit claims using valid code combinations from HIPAA-approved code sets, following standard industry coding guidelines (e.g., CPT, ICD-10, CMS CCI edits). Claims are subject to code edit protocols and review and providers may be asked to supply additional documentation.
Document history shows code changes on 03/01/2024: added CPT 88313 and removed CPT 88305 and 88314.
Billing, documentation, and denial risk
Submit accurate documentation and valid codes
Providers must submit accurate documentation of services and submit claims using valid code combinations from HIPAA‑approved code sets and follow standard coding guidelines; claims are subject to code edit protocols and review.
- Valid code combinations from HIPAA‑approved code sets
- Industry-standard coding guidelines (e.g., CPT, HCPCS, ICD-10)
- Claims subject to code edit protocols and claim review
Clinical documentation to support medical necessity
Document that the patient has symptoms of painful sensory neuropathy; explicitly note absence of disorders known to predispose to painful neuropathy (for example: diabetic neuropathy, toxic neuropathy, HIV neuropathy, celiac neuropathy, inherited neuropathy); record physical exam findings that show no evidence of large‑fiber neuropathy (eg, preserved muscle‑stretch reflexes, intact proprioception and vibration); and include normal electromyography and nerve‑conduction study results demonstrating no large‑fiber neuropathy to support reimbursement.
Not reimbursable outside specified criteria
Claims that do not meet ALL listed reimbursement criteria (the required symptom, absence of predisposing disorders, exam excluding large‑fiber neuropathy, and normal EMG/nerve‑conduction studies) and claims for measurement of sweat gland nerve fiber density are not reimbursable and may be denied.
Key definitions
Evidence and guideline references
Practice Parameter / Guidelines cited: Multiple guideline and literature references support the use of skin biopsy (ENFD measurement) for diagnosis of small-fiber neuropathy, including AAN practice parameters and EFNS/PNS guidelines, along with numerous peer‑reviewed studies and reviews that establish diagnostic utility and normative data.
These referenced guidelines and studies inform the policy’s reimbursement criteria, but plan documents determine product applicability and govern coverage in case of conflict.
Document revision history
New policy created
Reimbursement information revised for clarity; added code 88313; removed codes 88305 and 88314
Document updated with literature review; Reimbursement Information unchanged; References revised.
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