Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95870. We decided that the Plan does not have to pay for 95937 and 
95940.  
 
You asked the Plan to pay for procedure codes 95870, 95937, 95940 provided to the enrollee on August 2, 
2022.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
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. The definition of this code 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 records 
indicate separate recording was done of the limbs in the bilateral lower extremity and other muscle groups. 
This would suggest a clinically distinct procedure, as the measurement was not of the sphincter. The records 
otherwise supported separate recording. The records support that CPT 95870 was a separate procedure from 
CPT 51785. 
 
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 95937 and 95940. 
 
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 codes at issue is: 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95940: 
 
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring 
personal attendance, each 15 minutes (List separately in addition to code for 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 these codes. Our reviewer says that the records do 
not support CPT 95937 or CPT 95940 as separate and distinct procedures from CPT 51785. In terms of CPT 
95937 There was no testing done of the neuromuscular junction to reflect evaluation of a neuromuscular 
disorder. The performance of train of four testing is generally used as a marker of electromyography reliability. 
In as much, this was not distinct from the other codes. Nor is this code supported in the records. 
 
In terms of CPT 95940, the physician providing monitoring was located remotely to the operating room. 
Therefore, this code was not used appropriately. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95937 and 95940 have not been met. Therefore, we decided that the Plan does 
not have to pay for 95937 and 95940. 
 
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.