Abstract

This comprehensive US abdomen guideline outlines the adjudication process for related services, detailing coverage requirements, medical necessity criteria, and non-covered services across various categories. This document applies to all providers operating under agreements with NAS Administration Services Company LLC and Neuron LLC (collectively, NAS Neuron). Please note that the content is subject to periodic review and revision.

Diagnostic Ultrasound Abdomen

Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions. It is safe and painless. It produces pictures of the inside of the body using sound waves. Ultrasound imaging is also called sonography. It uses a small probe called a transducer and gel placed directly on the skin. High-frequency sound waves travel from the probe through the gel into the body. The probe collects the sounds that bounce back. A computer uses those sound waves to create an image. Ultrasound exams do not use radiation (x-rays). Because ultrasound captures images in real-time, it can show the structure and movement of the body's internal organs. The images can also show blood flowing through blood vessels.

Abdominal Ultrasound Coverage Criteria

The indications for performing an abdominal ultrasound include, but are not limited to, the following:

1. 1. Evaluation of Pain and Symptoms:

o Abdominal, flank, or back pain
o Signs or symptoms suggestive of abdominal or retroperitoneal pathology (e.g., jaundice, hematuria)

2. 2. Assessment of Palpable or Clinical Findings:

o Palpable abdominal masses
o Organomegaly or other suspected structural abnormalities

3. 3. Investigation of Abnormal Findings:

o Abnormal laboratory values or abnormal findings on other imaging examinations suggestive of abdominal and/or retroperitoneal pathology

4. 4. Monitoring and Follow-up:

o Follow-up of known or suspected abnormalities in the abdomen and/or retroperitoneum

5. 5. Trauma Assessment:

o Blunt or penetrating abdominal trauma

6. 6. Oncological Evaluation:

o Investigation of suspected metastatic disease
o Evaluation for occult primary neoplasm

7. 7. Renal and Urinary Tract Assessment:

o Urinary tract infection with suspected upper tract involvement
o Hydronephrosis evaluation
o Uncontrolled hypertension with suspected renal artery stenosis

8. 8. Fluid Detection:

o Evaluation for free or loculated peritoneal or retroperitoneal fluid

9. 9. Congenital and Pediatric Indications:

o Suspected congenital anomalies
o Evaluation of hypertrophic pyloric stenosis, intussusception, necrotizing enterocolitis, or other bowel abnormalities

10. 10. Transplant Evaluation:

o Pretransplant and posttransplant assessment of abdominal organs

11. 11. Procedural Support:

o Planning and real-time guidance for invasive abdominal procedures

Documentation requirement:

1. A clear and specific clinical indication (e.g., abdominal pain, palpable mass, jaundice).

2. Relevant history, signs, or symptoms supporting the medical necessity of the ultrasound.

3. Abnormal physical examination findings or prior diagnostic test results (labs or imaging) suggesting abdominal or retroperitoneal pathology

Ultrasound Abdomen - Complete study vs Limited study

❖ Complete Abdominal Ultrasound Study

A complete abdominal ultrasound involves a comprehensive evaluation of the major abdominal organs and structures.
The following structures must be evaluated and documented (unless contraindicated or non-visualized, with explanation):

1. o Liver
2. o Gallbladder
3. o Common bile duct
4. o Pancreas
5. o Spleen
6. o Both kidneys
7. o Upper abdominal aorta
8. o Inferior vena cava (IVC) (Including any demonstrated abdominal abnormality)



Documentation Requirements:

1. o Image documentation of each organ/structure listed above
2. o Final written report including interpretation of all evaluated regions
3. o If any required structure for a complete ultrasound is not visualized, a clear explanation must be documented in the report (e.g., obscured by bowel gas, surgically absent). In the absence of such documentation, the study must be down coded to a limited ultrasound and reporting it as a complete examination is not appropriate.
4. o A complete study should only be performed when clinically appropriate



❖ Limited Abdominal Ultrasound Study

A limited abdominal ultrasound focuses on specific organs, areas, or symptoms, rather than evaluating the entire abdomen.

Examples of limited study indications include:

1. o Evaluation of right upper quadrant pain (e.g., gallbladder only)
2. o Follow-up of a known lesion (e.g., liver or kidney mass)
3. o Assessment for free fluid (e.g., in trauma or post-surgical cases)
4. o Focused renal ultrasound in cases of flank pain or hematuria



Documentation Requirements:

1. o Image documentation of the targeted area(s)
2. o Final written report interpreting findings of the specific region(s) examined



Note - All diagnostic ultrasound examinations require permanently recorded images with measurements, when such measurements are clinically indicated.

Ultrasound examinations are only billable when the clinical indication justifies a thorough evaluation of the relevant organ(s) or anatomical region(s), accompanied by adequate image documentation and a finalized, signed report.

Use of ultrasound, without thorough evaluation of organ(s) or anatomic region, image documentation, and final, written report, is not separately reportable and is considered part of the consultation during which it was performed.

Non-Coverage Criteria

Ultrasound examinations will not be covered in the following situations:

1. o Lack of documented clinical indication or medical necessity
2. o Use of ultrasound for screening or routine check-ups without specific symptoms or findings
3. o Incomplete studies without proper evaluation of the relevant organ(s) or anatomical region(s)
4. o Duplicate or unnecessary repeat ultrasound exams without appropriate clinical justification
5. o Use of ultrasound to investigate conditions outside its accepted clinical scope
6. o Incorrect billing of a complete study when only a limited study was performed
7. o Performing multiple complete/limited ultrasounds on the same patient, on the same date of service, without appropriate clinical justification
8. o Lack of documentation supporting the scope and extent of the ultrasound performed, leading to mismatched billing
9. o Routine abdominal ultrasound for all patients with abdominal pain is not standard practice and should be guided by clinical evaluation.
10. o Overuse of ultrasound in nonspecific abdominal pain without appropriate indication may lead to non-coverage or denial of claims.

Applicable CPT Codes

CPT codes covered in the above section: -

CPT_CODE	FULL_DESCRIPTION
76700	Ultrasound, abdominal, real time with image documentation; complete
76705	Ultrasound, abdominal, real time with image documentation; limited (eg, single organ, quadrant, follow-up)

References

1. 1. Indications for abdominal imaging: When and what to choose? - PMC
2. 2. Reasons for inadequate or incomplete imaging techniques - PubMed
3. 3. Clinical indications for plain abdominal radiographs: A survey study among radiographers - PMC
4. 4. Evaluation of acute abdominal pain in adults - PubMed
5. 5. Acute Abdominal Pain in Adults: Evaluation and Diagnosis | AAFP

Effective Date:	Revision Date:	Version History:
15/12/2025	N/A	V1.0

Disclaimer

By accessing these NAS Neuron Adjudication Guidelines, you acknowledge and confirm that you have read, understood, and agreed to the terms outlined in this disclaimer. The information contained in these guidelines is intended solely to outline the adjudication procedures followed by NAS Neuron in the context of medical claims processing. These guidelines are not intended to be comprehensive and must not be construed as clinical treatment guidance. They are provided for general informational purposes only and are not intended to replace the clinical judgment of healthcare professionals. NAS Neuron does not engage in the provision of medical care or clinical decision-making and assumes no responsibility for any treatment decisions made by healthcare providers based on these guidelines. All decisions regarding patient care remain the sole responsibility of the treating healthcare provider. These guidelines do not create any legal rights or obligations for or against NAS Neuron. All content is provided “as is,” without any express or implied warranties, including but not limited to implied warranties of merchantability or fitness for a particular purpose.

Under no circumstances shall NAS Neuron be held liable for any direct, indirect, incidental, special, consequential, or punitive damages arising from the use of, access to, or reliance on these guidelines. This includes, without limitation, damages for loss of profits, business interruption, or loss of data, even if NAS Neuron has been advised of the possibility of such damages. These guidelines are subject to and governed by the applicable laws, decrees, circulars, and regulations of Dubai and the United Arab Emirates. They do not override or replace any applicable laws, formal contractual agreements, or regulatory directives issued by UAE governmental or regulatory authorities. This Adjudication Guideline is the intellectual property of NAS Neuron and may not be copied, reproduced, distributed, or displayed in whole or in part without the express written consent of NAS Neuron. These guidelines incorporate Current Procedural Terminology (CPT®), which is a registered trademark of the American Medical Association (AMA), with all associated codes and descriptions owned by the AMA. NAS Neuron reserves the right to amend, update, or withdraw these guidelines at any time without prior notice.

Abstract

This comprehensive Helicobacter pylori guideline outlines the adjudication process for related services, detailing coverage requirements, medical necessity criteria, and non-covered services across various categories. This document applies to all providers operating under agreements with NAS Administration Services Company LLC and Neuron LLC (collectively, NAS Neuron). Please note that the content is subject to periodic review and revision.

Helicobacter pylori (H. pylori)

Helicobacter pylori (H. pylori) is a spiral-shaped bacterium that colonizes the mucosal lining of the stomach and the duodenum—the initial segment of the small intestine. It is a common cause of chronic gastritis and peptic ulcer disease, leading to inflammation and ulceration of the gastric or duodenal mucosa. H. pylori infection affects over half of the global population.

Non-invasive testing for Helicobacter Pylori Infection

In patients with suspected Helicobacter pylori infection, the following laboratory tests are recommended to establish the diagnosis:

• Urea Breath Test (UBT): The urea breath test is a non-invasive, FDA-approved method for both initial diagnosis and post-treatment confirmation of Helicobacter pylori infection in adults and children over 3 years of age. It works by detecting labeled carbon dioxide in the breath, produced when H. pylori urease metabolizes ingested ¹³C- or ¹⁴C-labeled urea. Testing must be performed in a fasting state, with breath sample collection occurring approximately one hour after ingestion. The test is not recommended for children under 3 years, as performance data in this age group are insufficient.

• Stool Antigen Test for H. pylori: The stool antigen test is a reliable, non-invasive method for confirming active Helicobacter pylori infection. It detects H. pylori antigens in the stool and is suitable for both initial diagnosis and post-treatment confirmation of eradication. Stool antigen testing is the preferred FDA-approved method for diagnosing H. pylori infection in both pediatric and adult patients.

• Serologic Testing (IgG Antibody): H. pylori serology is no longer recommended by the American Gastroenterological Association (AGA) and the American College of Gastroenterology (ACG), as it cannot differentiate between active infection and past exposure. Furthermore, elevated antibody levels can persist for months to years’ post-treatment, making it unreliable for confirming eradication.

Test	Purpose	When to Use	Key Considerations	Eligibility Criteria
Urea Breath Test (UBT)	Detects active H. pylori infection	- Initial diagnosis - Post-treatment confirmation	- Perform while fasting - FDA-approved for adults and children >3 years - Highly accurate for active infection and eradication verification	- Adults and children over 3 years old - Must be off antibiotics, PPIs, or bismuth for at least 2 weeks prior to testing
Stool Antigen Test for H. pylori	Detects H. pylori antigens in stool	- Initial diagnosis - Post-treatment confirmation	- Non-invasive - FDA-approved for all ages - Reliable for confirming active infection and eradication	- All age groups (including infants and children) - Must be off antibiotics, PPIs, or bismuth for at least 2 weeks prior to testing
Serologic Testing (IgG Antibody)	Detects antibodies against H. pylori	- Indication of past exposure or current infection (not active) - Not recommended for confirming active infection or eradication	- Elevated antibodies persist long after treatment - Not recommended by AGA/ACG due to false positives - High rate of false positives may lead to unnecessary treatment	- All age groups - Not recommended for diagnosis of active infection or post-eradication confirmation

The American Gastroenterological Association no longer recommends serology (antibody) testing for diagnosing infection or evaluating treatment effectiveness as it is unable to distinguish between active infection and previous exposure to H. Pylori. It does not confirm eradication.

Economic studies showed that the use of stool antigen testing was the most cost-effective approach compared to urea breath testing as recommended in the European guideline with a Grade a, Level 1a evidence.

Fecal Antigen Test (FAT) is considered equivalent to the Urea Breath Test (UBT) in terms of sensitivity and specificity for diagnostic purposes; therefore, coverage will be restricted to Fecal Antigen Test only.

Experimental, Investigational, or Unproven

• Non-specific Dyspepsia: In the absence of alarm symptoms (e.g., anemia, gastrointestinal bleeding, weight loss, or obstruction), H. pylori testing is not necessary for dyspepsia.

• Patients already on therapy: Testing is not indicated in patients who have already undergone treatment for H. pylori unless confirming eradication.

• Routine Screening: H. pylori testing is not recommended for routine screening of asymptomatic individuals or those without a history of ulcers or related conditions.

• Simultaneous urea breath testing and stool antigen testing for H. pylori is not considered medically necessary, as concurrent testing with both methods is not required.

• Evaluating infantile colic.

• New-onset dyspepsia in persons aged 60 years or older.

• Prediction of the risk of gastric cancer or irritable bowel syndrome

• Screening of asymptomatic persons for H. pylori infection.

• American Gastroenterological Association no longer recommends serology (antibody) testing for diagnosing infection or evaluating treatment effectiveness as it is unable to distinguish between active infection and previous exposure to H. Pylori.

• Based on international recommendations, H. pylori serology testing & UBT C14 is not eligible for coverage.

Applicable CPT Codes

CPT codes covered in the above section: -

CPT_CODE	FULL_DESCRIPTION
83009	Helicobacter pylori, blood test analysis for urease activity, non-radioactive isotope (eg, C-13)
83013	Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope (eg, C-13)
83014	Helicobacter pylori; drug administration
86677	Antibody; Helicobacter pylori
87338	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori, stool
87339	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; Helicobacter pylori
78267	Urea breath test, C-14 (isotopic); acquisition for analysis
78268	Urea breath test, C-14 (isotopic); analysis

References

1. 1. H. pylori Infection: Symptoms, Causes, and Treatment
2. 2. Helicobacter pylori (H. pylori) infection - Symptoms & causes - Mayo Clinic
3. 3. Tests for H pylori: MedlinePlus Medical Encyclopedia
4. 4. Overview of Helicobacter pylori Infection: Clinical Features, Treatment, and Nutritional Aspects - PMC
5. 5. Helicobacter pylori Infection: Current Status and Future Prospects on Diagnostic, Therapeutic and Control Challenges - PMC
6. 6. Official journal of the American College of Gastroenterology | ACG
7. 7. PII: B978-0-240-80932-8.50001-6
8. 8. NICE Guideline Template

Effective Date:	Revision Date:	Version History:
15/12/2025	N/A	V1.0

Disclaimer

By accessing these NAS Neuron Adjudication Guidelines, you acknowledge and confirm that you have read, understood, and agreed to the terms outlined in this disclaimer. The information contained in these guidelines is intended solely to outline the adjudication procedures followed by NAS Neuron in the context of medical claims processing. These guidelines are not intended to be comprehensive and must not be construed as clinical treatment guidance. They are provided for general informational purposes only and are not intended to replace the clinical judgment of healthcare professionals. NAS Neuron does not engage in the provision of medical care or clinical decision-making and assumes no responsibility for any treatment decisions made by healthcare providers based on these guidelines. All decisions regarding patient care remain the sole responsibility of the treating healthcare provider. These guidelines do not create any legal rights or obligations for or against NAS Neuron. All content is provided “as is,” without any express or implied warranties, including but not limited to implied warranties of merchantability or fitness for a particular purpose. In cases where the payer has issued separate or specific clinical guidelines, the payer’s guidelines shall take precedence and will be applied accordingly.

Under no circumstances shall NAS Neuron be held liable for any direct, indirect, incidental, special, consequential, or punitive damages arising from the use of, access to, or reliance on these guidelines. This includes, without limitation, damages for loss of profits, business interruption, or loss of data, even if NAS Neuron has been advised of the possibility of such damages. These guidelines are subject to and governed by the applicable laws, decrees, circulars, and regulations of Dubai and the United Arab Emirates. They do not override or replace any applicable laws, formal contractual agreements, or regulatory directives issued by UAE governmental or regulatory authorities. This Adjudication Guideline is the intellectual property of NAS Neuron and may not be copied, reproduced, distributed, or displayed in whole or in part without the express written consent of NAS Neuron. These guidelines incorporate Current Procedural Terminology (CPT®), which is a registered trademark of the American Medical Association (AMA), with all associated codes and descriptions owned by the AMA. NAS Neuron reserves the right to amend, update, or withdraw these guidelines at any time without prior notice.

Abstract

This comprehensive vitamin D guideline outlines the adjudication process for vitamin D services, detailing coverage requirements, medical necessity criteria, and non-covered services across various categories. This document applies to all providers operating under agreements with NAS Administration Services Company LLC and Neuron LLC (collectively, NAS Neuron). Please note that the content is subject to periodic review and revision.

Vitamin D deficiency

Vitamin D deficiency is a condition where the body lacks adequate vitamin D to maintain normal calcium metabolism, bone health, and muscular function. It impairs bone mineralization and increases the risk of skeletal and possibly non skeletal disorders.

Medical Necessity in Testing for Vitamin D deficiency:

Testing for Vitamin D deficiency is considered medically necessary in patients with any of the following conditions:

Patient Type	Coverage criteria
Children (Up to 18 years of age)	•Deformed bones (bowlegs or knock knees) • Poor growth, delayed fontanelle closure • Delayed walking or a waddling gait • Tender or swollen joints, classically the wrists or costochondral junctions • Bone pain and tenderness • Delayed eruption of teeth or enamel hypoplasia • Carpopedal spasm, seizures or irritability • Breathing difficulties (apnoea or stridor) • All children with suspected metabolic bone disease, with relevant clinical features • Malabsorption syndromes
Adult	• Bone pain • Proximal myopathy • Low bone mineral density +- fracture • Laboratory features such as hypocalcaemia, hypophosphataemia and increased ALP are often a late presenting feature of vitamin D deficiency • Osteoporosis or significant risk of developing osteoporosis (e.g.: malabsorption, CF)

Repeat Testing for Vitamin D

Repeat blood testing for vitamin D is only required for a small number of clinical indications.

Routine monitoring of vitamin D levels in patients taking supplements is generally unnecessary, except under specific circumstances outlined below.

Clinical Situation	Recommendation
Vitamin D therapy and patient in one of the following categories (usually in conjunction with secondary care): • Osteoporosis • Malabsorption (to include cystic fibrosis and coeliac disease) • Chronic hepatic and renal disease • Taking anticonvulsants or similar medications • Children with clinical rickets	Covered only if repeated after 3-8 months on recommended replacement dose where baseline was low. Annual monitoring for patients on adequate replacement. Repeats will not be allowed before 3 months. All requests for repeat measurement will be reviewed. The clinical indication for repeat testing should be clearly mentioned.
Vitamin D therapy for whatever clinical indication where baseline Vitamin D concentration was low.	Do not retest, unless patient’s symptoms have not resolved or otherwise clinically indicated. Repeats will not be allowed before 3 months. All requests for repeat measurement will be reviewed. Clinical indication for repeat testing should be clearly mentioned.

Note –

• Coverage for the test may be considered when there are documented clinical indications or risk factors, supported by a comprehensive medical report that clearly establishes the medical necessity for performing the test.
• Coverage is subject to individual policy terms and conditions.

Risk factors for vitamin D deficiency

Risk factors for vitamin D deficiency" refer to conditions, behaviors, or characteristics that increase the likelihood of an individual having low serum levels of vitamin D.

Identifying these risk factors is important for guiding screening, prevention, and treatment efforts.

Inadequate UV light exposure	Gastrointestinal	Metabolic risk
• Occlusive garments • Pigmented skin • Institutionalised or housebound	• Vegetarian (or fish-free diet) • Malabsorption, short bowel or liver disease • Cholestyramine use	• Older people • Drugs (Rifampicin, anticonvulsants, antiretroviral therapy, high dose glucocorticoids) • Multiple, short interval pregnancies • Prolonged breast feeding without vitamin D supplementation

Exclusions for Vitamin D Testing and Monitoring

1. 1. Vitamin D testing is not indicated when baseline vitamin D concentrations are already known to be low and appropriate supplementation has commenced.
2. 2. Vitamin D testing is not medically indicated when the vitamin D concentration is adequate.
3. 3. Testing is not required in the absence of clinical signs or symptoms.
4. 4. Routine laboratory testing of blood vitamin D levels is not necessary.
5. 5. Non-specific symptoms such as tiredness, malaise and depression are usually not caused by vitamin D deficiency, and these symptoms rarely resolve with vitamin D supplementation.
6. 6. When a patient’s vitamin D levels have returned to normal, do not retest (do not arrange annual testing), especially if the patient has not changed their lifestyle or is still taking a supplement.
7. 7. Combined use of CPT® codes 82306 and 82652 for Vitamin D testing is not covered.

Applicable CPT Codes

CPT codes covered in the above section: -

CPT_CODE	FULL_DESCRIPTION
82306	Vitamin D; 25 hydroxy, includes fraction(s), if performed
82652	Vitamin D; 1, 25 dihydroxy, includes fraction(s), if performed

Note: -

1. 1. CPT 82306 : For Vitamin D deficiency testing
2. 2. CPT 82652: Use only for complex cases such as unexplained hypercalcemia/ hypercalciuria/ tumor-induced osteomalacia.

References

1. 1. Rickets Treatment & Management: Approach Considerations, Deterrence/Prevention
2. 2. Aspray TJ, Bowring C, Fraser W, et al; National Osteoporosis Society. National Osteoporosis Society vitamin D guideline summary. Age Ageing. 2014;43(5):592-595
3. 3. Chandra P, Binongo JN, Ziegler TR, et al. Cholecalciferol (vitamin D3) therapy and vitamin D insufficiency in patients with chronic kidney disease: A randomized controlled pilot study. Endocr Pract. 2008;14(1):10-17
4. 4. Kennel KA et al. Vitamin D deficiency in adults: When to test and how to treat. Mayo Clin Proc 2010; 85:752-758.
5. 5. IOM (Institute of Medicine). 2011 Dietary Reference Intakes for Calcium and Vitamin D. Washington DC: The National Academies Press 2010
6. 6. Holick MF et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011; 96:1911-30
7. 7. Vitamin D and Bone Health: A Practical Clinical Guideline for Patient Management; National Osteoporosis Society, April 2013
8. 8. WHO EMRO | The status of serum vitamin D in the population of the United Arab Emirates | Volume 22, issue 9 | EMHJ volume 22, 2016

Effective Date:	Revision Date:	Version History:
15/12/2025	N/A	V1.0

Disclaimer

By accessing these NAS Neuron Adjudication Guidelines, you acknowledge and confirm that you have read, understood, and agreed to the terms outlined in this disclaimer. The information contained in these guidelines is intended solely to outline the adjudication procedures followed by NAS Neuron in the context of medical claims processing. These guidelines are not intended to be comprehensive and must not be construed as clinical treatment guidance. They are provided for general informational purposes only and are not intended to replace the clinical judgment of healthcare professionals. NAS Neuron does not engage in the provision of medical care or clinical decision-making and assumes no responsibility for any treatment decisions made by healthcare providers based on these guidelines. All decisions regarding patient care remain the sole responsibility of the treating healthcare provider. These guidelines do not create any legal rights or obligations for or against NAS Neuron. All content is provided “as is,” without any express or implied warranties, including but not limited to implied warranties of merchantability or fitness for a particular purpose.

Under no circumstances shall NAS Neuron be held liable for any direct, indirect, incidental, special, consequential, or punitive damages arising from the use of, access to, or reliance on these guidelines. This includes, without limitation, damages for loss of profits, business interruption, or loss of data, even if NAS Neuron has been advised of the possibility of such damages. These guidelines are subject to and governed by the applicable laws, decrees, circulars, and regulations of Dubai and the United Arab Emirates. They do not override or replace any applicable laws, formal contractual agreements, or regulatory directives issued by UAE governmental or regulatory authorities. This Adjudication Guideline is the intellectual property of NAS Neuron and may not be copied, reproduced, distributed, or displayed in whole or in part without the express written consent of NAS Neuron. These guidelines incorporate Current Procedural Terminology (CPT®), which is a registered trademark of the American Medical Association (AMA), with all associated codes and descriptions owned by the AMA. NAS Neuron reserves the right to amend, update, or withdraw these guidelines at any time without prior notice.

Abstract

This comprehensive NCS & EMG testing guideline outlines the adjudication process for NCS & EMG testing services, detailing coverage requirements, medical necessity criteria, and non-covered services across various categories. This document applies to all providers operating under agreements with NAS Administration Services Company LLC and Neuron LLC (collectively, NAS Neuron). Please note that the content is subject to periodic review and revision.

Electrodiagnostic tests (EDX)

Electrodiagnostic tests are electrophysiological techniques used to evaluate the function and integrity of neuromuscular components, including peripheral nerves, nerve roots, plexuses, the neuromuscular junction (NMJ), and muscles.

These tests are classified into 2 primary types—needle electromyography (EMG) and nerve conduction studies (NCS). Both NCS and EMG record electrical activity in the peripheral nerves and muscles.

Nerve conduction study

A nerve conduction study (NCS) is a medical test used to assess the health and functioning of the peripheral nervous system, which includes the nerves outside the brain and spinal cord. It is a diagnostic procedure that helps in evaluating nerve damage, detecting nerve-related disorders, and determining the extent and location of nerve injuries or abnormalities.

Types of NCS

NCS is classified into 3 main types—motor, sensory, and mixed.

Motor NCS

To determine the motor conduction velocity of a motor nerve, electrical stimulation is applied at multiple points along the nerve, and the resulting responses are recorded from the corresponding muscle.

Sensory NCS

To determine the sensory conduction velocity of a nerve, electrical stimulation is applied near the sensory nerve, and the resulting response is recorded at a different site along the nerve.

Mixed NCS

Mixed nerve conduction studies (MNCS) evaluate both motor and sensory components of a mixed nerve by applying electrical stimulation at a distal site and recording the resulting mixed nerve action potentials (MNAPs) from a more proximal point along the same mixed nerve.

Electromyogram (EMG)

Electromyography (EMG) is a diagnostic procedure that records the electrical activity of muscles at rest and during voluntary contraction. It is used to evaluate the integrity and function of muscles and their innervating nerves. EMG is indicated in the assessment of neuromuscular junction disorders, peripheral nerve pathologies, and primary muscle diseases.

Indications

NCV studies are effective in assessing the pathophysiology of peripheral nerve disorders. Electrodiagnostic studies are typically performed as an adjunct to clinical examination. NCS is valuable in confirming clinical diagnoses and can also help identify subclinical conditions, localize focal nerve abnormalities, measure severity, and characterize the nature of the lesion.

Common indications include focal nerve entrapments, demyelinating mononeuropathy, axonal loss mononeuropathy, preganglionic lesions, and both demyelinating and axonal polyneuropathies.

Indications for Nerve Conduction Studies (NCS) in Neurological Conditions

Common indications for NCS include the evaluation of:

1. 1. Focal nerve entrapments
2. 2. Demyelinating mononeuropathy
3. 3. Axonal loss mononeuropathy
4. 4. Preganglionic lesions
5. 5. Both demyelinating and axonal polyneuropathies.

Indications for EMG in Suspected Neuromuscular Disorders

1. 1. Upper motor neuron (UMN) lesions
2. 2. Lower motor neuron (LMN) lesions
3. 3. Anterior horn cell disorders (e.g., ALS)
4. 4. Radiculopathies (nerve root compression or inflammation)
5. 5. Plexopathies (brachial or lumbosacral plexus disorders)
6. 6. Mononeuropathies (e.g., carpal tunnel syndrome)
7. 7. Neuromuscular junction (NMJ) disorders (e.g., myasthenia gravis)
8. 8. Myopathies or primary muscle disorders (e.g., muscular dystrophies, polymyositis)

EDX (electrodiagnostic) testing is used to evaluate the integrity and function of the peripheral nervous system (most cranial nerves, spinal roots, plexi, and nerves), neuromuscular junction, muscles, and the central nervous system (brain and spinal cord).

AANEM Recommended Number of Studies/Tests Per Date of Service

Codes 95907-95913 describe one or more nerve conduction studies.

For the purposes of coding, a single conduction study is defined as a sensory conduction test, a motor conduction test with or without an F wave test, or an H-reflex test.

Each type of study (sensory, motor with or without F wave, H-reflex) for each nerve includes all orthodromic and antidromic impulses associated with that nerve and constitutes a distinct study when determining the number of studies in each grouping (eg, 1-2 or 3-4 nerve conduction studies).

Each type of nerve conduction study is counted only once when multiple sites on the same nerve are stimulated or recorded.

Limitations

The following are considered not medically reasonable and necessary:

1. NCSs or EMG for muscle pain without the presence of other abnormalities on examination or in laboratory testing.
2. Screening testing, monitoring disease intensity, or monitoring treatment efficacy for polyneuropathy of diabetes or polyneuropathy of end stage renal disease (ESRD).
3. For evaluation of COVID-19 associated neuromuscular disorders & Peyronie's disease.
4. Electro-diagnostic tests (e.g., EMG and NCV studies) for the diagnosis of distal symmetric polyneuropathy.
5. Intraoperative NCV studies, including those performed during prostatectomy/prostate surgery and wrist arthroscopy repair.
6. Phrenic nerve conduction study for evaluation of phrenic nerve function of lung transplant candidate.
7. NCV studies for diagnosis of organophosphorus pesticide exposure.
8. Quantitative Sensory Testing (QST) (e.g., hot-cold, touch, vibration).
9. NCSs accomplished with discriminatory devices that use fixed anatomic templates and computer-generated reports used as an adjunct to physical examination routinely on all patients.
10. Physiologic recording of movement disorder symptoms, including bradykinesia, dyskinesia, and tremor using wearable devices with accelerometers or gyroscopes.
11. NEMG for the following situations:
    • Definitive diagnosis based on paraspinal NEMG in areas with scar from past surgeries (e.g., previous laminectomies)
    • Surface electromyography (SEMG)
    • Macro electromyography (macro-EMG)
    • NEMG for isolated neck or back pain after a motor vehicle accident
12. Studies performed beyond the reasonable maximum number of studies recommended in the American Medical Association (AMA) Current Procedural Terminology (CPT®) Codebook, Appendix J, Electrodiagnostic Medicine Listing of Sensory, Motor, and Mixed Nerves. These recommendations are supported by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). Additional studies may be considered upon redetermination.
13. Nerve conduction studies (NCS) are not covered when performed solely for screening purposes.
14. NCS is not covered unless supported by a medically necessary indication or diagnosis.
15. Repeating EDX (electrodiagnostic) studies within a 12-month period is not warranted in the absence of new or worsening symptoms.
16. Electrodiagnostic studies should also be avoided in cases of open skin infections, surface burns, or recent skin grafts.
17. Absolute contraindications include conditions that prevent the use of surface electrodes, such as areas covered by a splint or cast.
18. Patients with bleeding tendencies and suppressed immune responses should be evaluated on a case-by-case basis.
19. EMG is contraindicated in patients with a platelet count below 50,000/dL.
20. EMG is performed with caution in patients taking antiplatelet or anticoagulant medications.
21. Guidelines advise against performing NCS in patients with intracardiac catheters and external pacing wires. (implanted pacemakers and cardiac defibrillators)
22. Performing multiple needle EMG studies on the same patient, at the same location of the same limb, solely for the purpose of optimizing botulinum toxin injections, is not considered medically indicated.
23. EMG is not medically indicated for pattern-setting limited limb muscle examinations performed without paraspinal muscle testing, as these are not sufficient to establish a diagnosis of radiculopathy.
24. EMG is not medically indicated for making definitive diagnostic conclusions based solely on paraspinal EMG in regions with surgical scarring (e.g., prior laminectomies).
25. Needle EMG is not medically indicated when limited to exclusive testing of intrinsic foot muscles for the diagnosis of proximal lesions.

Documentation Requirements

1. The member's medical records must clearly document the medical necessity for the test.
2. Data gathered during NCS, should be available which reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular format.
3. The reason for referral and a clear diagnostic impression are required for each study. In cases where a review becomes necessary, either a hard copy of waveforms or a complete written report with an interpretation of the test must be submitted upon request.
4. Normal findings and abnormalities uncovered during the study should be documented with the muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation.

Applicable CPT Codes

CPT codes covered in the above section: -

CPT_CODE	FULL_DESCRIPTION
95907	Nerve conduction studies; 1-2 studies
95908	Nerve conduction studies; 3-4 studies
95909	Nerve conduction studies; 5-6 studies
95910	Nerve conduction studies; 7-8 studies
95911	Nerve conduction studies; 9-10 studies
95912	Nerve conduction studies; 11-12 studies
95913	Nerve conduction studies; 13 or more studies
95860	Needle electromyography; 1 extremity with or without related paraspinal areas
95861	Needle electromyography; 2 extremities with or without related paraspinal areas
95863	Needle electromyography; 3 extremities with or without related paraspinal areas
95864	Needle electromyography; 4 extremities with or without related paraspinal areas
95885	Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)
95886	Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)

References

1. 1. The electrodiagnostic evaluation is an extension of the neurologic portion of the physical examination
2. 2. rptresultsemgncs-pdf.pdf
3. 3. credentialing-of-edx-physicians.pdf
4. 4. model-policy-for-needle-emg-and-ncss-final.pdf
5. 5. who-is-qualified-to-practice-edx-medicine.pdf
6. 6. Nerve Conduction Studies and Electromyography - StatPearls - NCBI Bookshelf
7. 7. LCD - Nerve Conduction Studies and Electromyography (L34859)
8. 8. https://www.aanem.org/docs/default-source/documents/aanem/practice/recommended-policy-edx-medicine-062810.pdf?sfvrsn=93f935cc_0

Effective Date:	Revision Date:	Version History:
15/12/2025	N/A	V1.0

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