Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for neuromuscular junction testing (95937), central motor evoked potential study (95939), short-latency somatosensory evoked potential study (95938), needle electromyography (95861) and continuous intraoperative neurophysiology monitoring (G0453) provided on September 25, 2020.
You asked the Plan to pay for neuromuscular junction testing, central motor evoked potential study, short-latency somatosensory evoked potential study, needle electromyography and continuous intraoperative neurophysiology monitoring. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the
Plan was correct in denying the request to pay for neuromuscular junction testing, central motor evoked
potential study, short-latency somatosensory evoked potential study, needle electromyography and continuous
intraoperative neurophysiology monitoring. Our reviewer says that the medical records do not include
sufficient documentation to validate that Neuromuscular junction testing (repetitive stimulation, paired stimuli),
each nerve, any 1 method was performed on September 25, 2020, therefore this service cannot be verified. The
medical records do not include sufficient documentation to validate that Central motor evoked potential study
(transcranial motor stimulation); in upper and lower limbs was performed on September 25, 2020, therefore
this service cannot be verified. Our reviewer found the medical records do not include sufficient documentation
to validate that Short - latency somatosensory evoked potential study, stimulation of any/all peripheral nerves
or skin sites recording from the central nervous system; in upper and lower limbs was performed on September
25, 2020, therefore this service cannot be verified. The medical records do not include sufficient documentation
to validate that Needle electromyography; 2 extremities with or without related paraspinal areas was performed
on September 25, 2020, therefore this service cannot be verified. The medical records do not include sufficient
documentation to validate that -continuous intraoperative neurophysiology monitoring, from outside the
operating room, per patient, each 15 minutes was performed on September 25, 2020, therefore this service
cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of neuromuscular junction testing, central motor evoked potential study, shortlatency
somatosensory evoked potential study, needle electromyography and continuous intraoperative
neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for
neuromuscular junction testing (95937), central motor evoked potential study (95939), short-latency
somatosensory evoked potential study (95938), needle electromyography (95861) and continuous
intraoperative neurophysiology monitoring (G0453) provided on September 25, 2020.