Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) G0453. We decided that 
the Plan does not have to pay for the services described by procedure code(s) 95870.  
 
You asked the Plan to pay for procedure codes 95870 and G0453 billed for date of service August 18, 2022. 
You say that these services were necessary and are supported as billed. The Plan says that the payment for code 
95870 is included in the payment for code 95861. Although this code pair was billed with a modifier for 
separate payment, the medical records do not support that this modifier was used appropriately. 
 
We decided that the Plan has to pay for the services described by procedure code(s) G0453.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section, nor did the Plan indicate or provide evidence to show that this code has been paid. The Plan is not 
allowed to reopen any determinations while an appeal is pending and must issue a determination on all 
appealed services within the appeal time frame. As the Plan forfeited its opportunity to provide a denial 
rationale for these services, we find that the denial of payment is not supported. Therefore, we decided that the 
Plan has to pay for the services described by procedure code(s) G0453.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
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, we have confirmed that code 95870 
is a column II code to column I code 95861 however, procedure code 95870 was billed with a modifier.  
 
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 procedure code 95870. Our reviewer says that this service is 
not supported as separately identifiable. Our reviewer found that the needle electromyography services 
performed were included in procedure 95861. The use of the 59 modifier is not appropriate in this case. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) 95870 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
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.