Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95861. We decided that the Plan does not have to pay for G0453 and 
95870.  
 
You asked the Plan to pay for needle electromyography and continuous intraoperative monitoring (procedure 
codes 95861, 95870, and G0453) provided to the enrollee on March 8, 2022. You say that this should be paid 
for. The Plan says that the denied codes are not supported by the medical records submitted. 
 
We decided that the Plan has to pay for 95861.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 95861 is "Needle 
electromyography; 2 extremities with or without related paraspinal areas." 
 
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 95861. Our physician reviewer found that the 
records do support that CPT 95861 was rendered in this case. The neurodiagnostic report cite somatosensory 
evoked potentials (SSEPs) of the upper and lower extremities were obtained and processed. Bilateral needle 
EMG (95861) subdermal needle electrodes were placed in the corresponding myotomes in relation to the 
operative levels bilaterally, and no spontaneous electromyographic activity was observed at baselines. This 
supports that bilateral (2 extremities) were studied in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
95861.  
 
We also decided that the Plan does not have to pay for G0453 and 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. The definition of the remaining denied codes is: 
 
CPT 95870: 
 
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 
 
Healthcare Common Procedure Coding System (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) 
 
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 
neurodiagnostic report cites anal sphincter electromyography was obtained by subdermal electrodes being 
placed in the anal sphincter to monitor the EMG responses during the procedure. This supports that the 
electromyography was of a sphincter. Therefore, the records do not support that CPT 95870: 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 was rendered in this case. 
 Additionally, in this case, we have confirmed that HCPCS G0453 is a column II code to the column I code 
CPT 51785. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0453 and 95870 have not been met. Therefore, we decided that the Plan does 
not have to pay for G0453 and 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.