Electromyography (EMG)
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Defines medical necessity, coverage limitations, and billing guidance for electromyography (EMG) studies for Highmark Pennsylvania commercial lines of business.
No material clinical or coverage changes in this revision.
Coverage Criteria — When EMG is Medically Necessary
Medically Necessary Indications
Electromyography (EMG) may be considered medically necessary for ANY ONE of the following:
EMG covered if any one condition applies
Electromyography (EMG) for indications other than the conditions listed as medically necessary in this policy is not medically necessary and therefore non‑covered. The covered indications are limited to the specific clinical scenarios enumerated in the policy (e.g., nerve compression syndromes, radiculopathy, mono/polyneuropathy, myopathy, plexopathy, neuromuscular junction disorders, and localization prior to botulinum toxin or phenol injections). A “surface” EMG and macro EMG are specifically considered experimental/investigational and non‑covered because current scientific evidence does not support their use.
Any EMG performed for an indication that is not among the listed covered conditions will be considered not medically necessary and will not be covered. In addition to being non‑covered, surface EMG and macro EMG are classified as experimental/investigational. Providers billing for experimental/investigational services must follow member financial consent requirements described elsewhere in the policy when applicable.
Coding, Limits, and Billing Guidance
| 95907-95913 | H-reflex testing |
| 92265 | Referenced procedure code requiring post-payment diagnosis code application |
| 95867 | Referenced procedure code requiring post-payment diagnosis code application |
| 95868 | Referenced procedure code requiring post-payment diagnosis code application |
| 95874 | Referenced procedure code requiring post-payment diagnosis code application |
Provider Responsibilities and Claims Handling
Pre-payment application
This policy is applied on a pre-payment basis for both professional and facility claims. Certain diagnosis-code applications and limits are applied post-payment as noted below.
- Professional claims: policy applied on a pre-payment basis; diagnosis codes for 92265, 95867, 95868, 95874 reviewed post-payment.
- Facility claims: policy applied on a pre-payment basis; diagnosis codes for 92265, 95867, 95868, 95874 reviewed post-payment.
- H-reflex testing (95907-95913): limit to one unilateral or bilateral study per session per code.
- Neuromuscular junction testing (repetitive stimulation): limit to two repetitive stimulations per session.
- Services paid on initial processing may be subject to retrospective review.
Denial triggers
Services that do not meet the criteria of this policy will be denied as not medically necessary. Experimental/investigational (E/I) services are not covered. A network provider cannot bill the member for a denied service unless the provider has provided advance written notice, a cost estimate, and obtained the member's written agreement to assume financial responsibility in advance; the signed agreement must be maintained in the provider’s records.
- Denied services: provider must give advance written notice, cost estimate, and obtain member's written agreement to bill for denied service; keep signed agreement in records.
- Experimental/investigational services: not covered; provider must follow E/I consent rules (see below) if billing member.
Member financial consent for E/I services
If a provider intends to bill a member for an experimental/investigational (E/I) service, the provider must give advance written notice that the service has been deemed E/I, provide the member with an estimate of the cost, and obtain the member’s written agreement to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
- Applies when billing member for E/I services — advance written notice required.
- Member must receive a cost estimate and provide written consent assuming financial responsibility.
- Signed agreement must be retained in provider records.
Providers should follow billing and coding limits specific to EMG/NCV services and referenced Medical Policy Bulletins. Surface EMG and macro EMG are considered experimental/investigational and non-covered. Refer to M-51 for NCV studies and M-13 for intraoperative neurophysiologic monitoring.
- Surface EMG and macro EMG: non-covered (E/I).
- Refer to M-51 for Nerve Conduction Velocity (NCV) studies.
- Refer to M-13 for Intraoperative Neurophysiologic Monitoring guidance.
Background
Electromyography (EMG) is the study and recording of the intrinsic electrical properties of skeletal muscle. EMG results reflect both the integrity of the functional connection between a nerve and its innervated muscle and the integrity of the muscle itself. EMG is used to evaluate conditions such as nerve compression syndromes (including carpal tunnel), radiculopathies, mono‑ or polyneuropathies, myopathies, plexopathies, and neuromuscular junction disorders, and to assist with localization prior to certain neurotoxin or chemodenervation procedures.
Definitions and Testing Types
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