Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Neurological studies: needle electromyography (95886), neurological studies (95909), electroencephalogram (EEG) (95816), and audiological function tests (92557 and 92585).
You asked the Plan to pre-approve the services. You say that the member was experiencing symptoms of after a fall with loss of consciousness: Dizziness, Imbalance, Low back pain, Bilateral leg weakness. The Plan denied your request. The Plan says the services are not necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our physician reviewer found for the NCS (95909)--there was no indication in the records to suggest that the member has focal neuropathies or compressive lesions. Nor is there any evidence of a generalized neuropathy (based on the limited history provided and exam findings). In this setting the clinical information provided would not support provision of an NCS as the requirements of the LCD were not met. Nor did the (limited) records provided for review suggest the presence of a condition for which the LCD covers the use of an EMG. The member is only noted to have a complaint of low back pain. There was no (legible) description of radicular symptoms. Likewise, there was no indication that the member had a neuropathy, myopathy or NMJ disorder. In that regard EMG would not readily be expected to be of formal diagnostic utility. For the EEG (95816) and BAER (92557 and 92585)--these services would also not meet the Medicare definition of medical necessity. Rather, the services would not meet the following requirement for coverage: "Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is: - Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member" The member has complaints of "Dizziness". However, there is nothing to suggest that the patient has a seizure disorder or similar condition for which EEG would be expected to be of diagnostic utility. EEG is essentially non-diagnostic for complaints of non-specific dizziness. Provision of such testing in this situation is not consistent with the generally accepted standards of practice as it is not generally considered to be clinically appropriate. Likewise, for the BAER/BAEP testing (92557 and 92585)--the member is not noted to have a disorder/condition for which BAER/BAEP would be expected to be of diagnostic utility. There was no evidence of hearing loss (the primary indication for which such testing is performed and is otherwise of utility). There was otherwise nothing to suggest that the member had any form of cranial nerve dysfunction. In as much this service would also not be furnished in a manner consistent with the generally accepted standards of practice or care. Therefore, this would also not meet Medicare criteria for coverage. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve Neurological studies: needle electromyography (95886), neurological studies (95909), electroencephalogram (EEG) (95816), and audiological function tests (92557 and 92585).