Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 95870. We decided that the Plan does not have to pay for CPT 
95999.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
We decided that the Plan has to pay for 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 CPT Code Manual 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 physician reviewer found that the 
records in this case do demonstrate that a free running electromyography (EMG) had been performed during 
the course of the monitoring. This was clearly stated in the records provided for review. Therefore, it can be 
said that CPT 95870 is supported. 
 
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 
95870.  
 
We also decided that the Plan does not have to pay for 95999. 
 
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 CPT Code Manual definition of CPT 95999 is "Unlisted neurological or neuromuscular 
diagnostic 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 95999. Our physician reviewer found that 
CPT 95999 is not otherwise supported. A peripheral nerve stimulator, also known as a train-of-four monitor, is 
used to assess neuromuscular transmission when neuromuscular blocking agents are given to block 
musculoskeletal activity. By assessing the depth of neuromuscular blockade, peripheral nerve stimulation can 
ensure proper medication dosing and, thus, decrease the incidence of side effects. Train-of-four monitoring is 
bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials 
(MEP) and, therefore, is not separately reportable. This was reported in the CPT Assistant in February 2016. 
Therefore, CPT 95999 would not be supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95999 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95999. 
 
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.