Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for needle electromyography (EMG) test (95861). We decided that the 
Plan does not have to pay for and needle electromyography studies (51785).  
 
You asked the Plan to pay for the electromyography services. You say that these services were billed correctly 
and are supported in the record. The Plan denied your request. The Plan says these services were not billed 
appropriately as 95861 is included in another paid service (95939) and 51785 is not supported in the medical 
records submitted. 
 
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 the electromyography services. 
 
We decided that the Plan has to pay for needle electromyography test (95861).  
 
The Plan denied payment for this service, stating that this code/service is included in the central motor evoked 
potential study (95939) which was already approved for payment. Our reviewer says that this service meets 
Medicare criteria for coverage. Our reviewer found, after thorough research and review of guidelines for 
intraoperative neuromonitoring, no guidelines were found to support an EMG of upper and lower extremities 
are inclusive to a motor evoked potential upper and lower extremities as these are different procedures. There is 
also no National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit between this code pair. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of needle electromyography test (95861) have been met. Therefore, we decided 
that the Plan has to pay for the needle electromyography test (95861) provided on May 18, 2021.  
 
We also decided that the Plan does not have to pay for and needle electromyography studies (51785). 
 
Our reviewer says that this service does not meet criteria for Medicare coverage. Our reviewer found that there 
is no documentation to support that electrical activity was measured with the bladder filled and during 
emptying to determine if the bladder is functioning properly. Documentation does not support that this service 
was provided as billed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of and needle electromyography studies (51785) have not been met. Therefore, we 
decided that the Plan does not have to pay for the needle electromyography studies (51785) provided on May 
18, 2021. 
 
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.