Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 51785 and 95870. We decided that the Plan does not 
have to pay for procedure code 95861.  
 
You asked the Plan to pay for procedure codes 51785, 95861 and 95870 billed for date of service June 7, 2022.. 
You say that the services at issue have been billed correctly. The Plan says that rules for payment have not been 
met because records do not support the services billed. 
 
We decided that the Plan has to pay for procedure codes 51785 and 95870.  
 
The Plan follows 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 code 
51785 is: Needle electromyography studies (EMG) of anal or urethral sphincter, any technique; and of code 
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. 
Additionally, we have confirmed that code 95870 is a column II code to column I codes 51785 and 95861; 
however, 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 codes 51785 and 95870. Our reviewer says that 
procedure codes 51785 and 95870 meet criteria for payment. Our physician reviewer found that the available 
medical documentation supports the use of procedure code 51785 as it was documented as performed. Medical 
records also support the use of procedure code 95870, to be used with appropriate modifier 59 since there is a 
relationship with 95870 and 51785. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 51785 and 95870 have been met. Therefore, we decided that 
the Plan has to pay for procedure codes 51785 and 95870.  
 
We also decided that the Plan does not have to pay for procedure code 95861. 
 
The Plan follows 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 code 
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 to pay for procedure code 95861. Our reviewer says 
that procedure code 95861 does not meet criteria for payment. Our physician reviewer found that the medical 
records do not support the use of procedure code 95861 as having been performed in addition to procedure 
code 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 procedure code 95861 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 95861. 
 
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.