Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for HCPCS G0453, CPT 95938, and CPT 95939. We decided that the Plan
does not have to pay for CPT 95870.
You asked the Plan to pay for the denied codes. You say that this should be paid for. The Plan says that the
submitted medical records do not contain sufficient detail to support the billed charges.
We decided that the Plan has to pay for HCPCS G0453, CPT 95938, and CPT 95939.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the definition of the codes at issue is:
HCPCS G0453:
Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby),
per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary
procedure)
CPT 95939:
central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs
CPT 95938:
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
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 for the above denied codes. Our reviewer says that the
medical records support these codes. Our physician reviewer found that CPT 95938 should be overturned. The
documentation supports that upper and lower extremity SSEPs were performed. CPT 95939 should be
overturned. The documentation supports that upper and lower extremity MEPs were performed. G0453 x 15
should be overturned. The documentation supports that that 3hrs and 45mins of monitoring was provided from
outside of the operating room.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of HCPCS G0453, CPT 95938, and CPT 95939 have been met. Therefore, we
decided that the Plan has to pay for HCPCS G0453, CPT 95938, and CPT 95939.
We also decided that the Plan does not have to pay for CPT 95870.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the definition of CPT 95870 is:
"needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters."
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 for CPT 95870. Our reviewer says that the medical
records do not support this code. Our physician reviewer found that the documentation does not support that
limited EMGs were performed. The documentation shows that complete, bilateral, upper extremity EMGs were
performed and the provider noted that this was to be billed as 95861.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of CPT 95870 have not been met. Therefore, we decided that the Plan does not
have to pay for CPT 95870.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.