Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Surface Electromyography (SEMG)
Ancillary Services
Effective Date:
June 1, 2020
Issued Date:
June 28, 2021
Last Revision Date:
May 2020
Annual Review:
June 2021

This policy version was replaced June 27, 2022. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Electromyography (EMG) is an electrodiagnostic technique for recording the extracellular activity of skeletal muscles at rest, during voluntary contractions, and during electrical stimulation. Needle EMG, the gold standard for evaluating the electrical activity of muscles, is an invasive procedure that records the activity of individual muscles. Surface EMG records the electrical activity of groups of muscles through placement of electrodes on the surface of the skin.

Surface EMG (SEMG) may be characterized in several ways, including but not limited to paraspinal, high-density (more than 2 closely spaced electrodes), dynamic (performed during or after exercise) or macro (more than one muscle fiber) SEMG.  The technology has been proposed for a variety of clinical indications including: clarification of a diagnosis (i.e., muscle, joint, or disk disease), follow-up of acute back pain, evaluation of exacerbation of chronic back pain, evaluation of pain management treatment techniques, and evaluation and monitoring of temporomandibular disorder (TMD).

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

The use of surface electromyography (SEMG) is considered EXPERIMENTAL/INVESTIGATIVE for all indications, including temporomandibular disorder (TMD), due to lack of clinical evidence indicating its impact on improved health outcomes.

95999 97799 99199 S3900

Denial Statements

No additional statements.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies. When determining coverage, reference the member’s specific benefit plan, including exclusions and limitations.

Medicaid products may provide different coverage for certain services, which may be addressed in different policies. For Minnesota Health Care Program (MHCP) policies, please consult the MHCP Provider Manual website.

Medicare products may provide different coverage for certain services, which may be addressed in different policies. For Medicare National Coverage Determinations (NCD), Local Coverage Determinations (LCD), and/or Local Coverage Articles, please consult CMS, National Government Services, or CGS websites. 

Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and/or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. 

These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.


CPT® codes copyright American Medical Association® 2022. All rights reserved.

CDT codes copyright American Dental Association® 2022. All rights reserved.