Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the somatosensory testing (95938). We decided that the Plan does not 
have to pay for the continuous intraoperative neurophysiology monitoring (G0453), digital analysis of 
electroencephalogram (EEG) (95957), needle electromyography (codes 95861 and 95868), and neuromuscular 
junction testing (95937).  
 
You asked the Plan to pay for the somatosensory testing (95938), continuous intraoperative neurophysiology 
monitoring (G0453), digital analysis of EEG (95957), needle electromyography (codes 95861 and 95868), and 
neuromuscular junction testing (95937) provided on April 22, 2022. You say that you would like payment to be 
remitted accordingly. The Plan says that they do not have the needed information to consider this charge. 
 
We decided that the Plan has to pay for the somatosensory testing (95938).  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is medically 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 pay for the somatosensory testing (95938). Our 
reviewer says that the somatosensory testing is considered medically reasonable and necessary in this case. Our 
physician reviewer found the use of somatosensory evoked potentials (SSEPs) in surgery involving the cervical 
spine has long been supported by the relevant practice guidelines. Our reviewer found that the use of this 
modality in intraoperative neurophysiological monitoring (IONM) in multilevel cervical spinal procedures 
otherwise reflects standards of care/practice. As such this service was reasonable and necessary. 
 
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 somatosensory testing have been met. Therefore, we decided that the Plan 
has to pay for the somatosensory testing (95938).  
 
We also decided that the Plan does not have to pay for the continuous intraoperative neurophysiology 
monitoring (G0453), digital analysis of electroencephalogram (EEG) (95957), needle electromyography 
(codes 95861 and 95868), and neuromuscular junction testing (95937). 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate Current Procedural Terminology (CPT) code. 
 
In this case, the CPT Code Manual definition of code G0453 is continuous intraoperative neurophysiology 
monitoring. The CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram 
(EEG). The CPT Code Manual definition of codes 95861 and 95868 are needle electromyography. The CPT 
Code Manual definition of code 95937 is neuromuscular junction testing. 
 
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 pay for the continuous intraoperative 
neurophysiology monitoring (G0453), digital analysis of EEG (95957), needle electromyography (codes 95861 
and 95868), and neuromuscular junction testing (95937). Our reviewer says that the requested items/services 
are not considered medically reasonable and necessary in this case. Our physician reviewer found the 
documentation does not support that the continuous intraoperative neurophysiology monitoring, digital analysis 
of EEG, needle electromyography, and neuromuscular junction testing were provided. 
 
 
 
 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 continuous intraoperative neurophysiology monitoring, digital analysis of 
EEG, needle electromyography, and neuromuscular junction testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring (G0453), 
digital analysis of electroencephalogram (EEG) (95957), needle electromyography (codes 95861 and 95868), 
and neuromuscular junction testing (95937). 
 
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.