Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for the short-latency somatosensory evoked potential (SSEP) study. We decided that the Plan does not have to pay for the electromyography (EMG) and the central motor evoked potential (MEP) study.

You asked the Plan to pay for needle electromyography (EMG), short-latency somatosensory evoked potential (SSEP) study, and central motor evoked potential (MEP) study rendered on May 17, 2022.. You say that this was medically necessary. The Plan says that this service does not meet the coverage requirements.

We decided that the Plan has to pay for the short-latency somatosensory evoked potential (SSEP) study.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

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 these services Our reviewer says that SSEPs can be appropriate for intraoperative monitoring. Therefore, the SSEP can be said to have been supported by the LCD.

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 the short-latency somatosensory evoked potential (SSEP) study.

We also decided that the Plan does not have to pay for the electromyography (EMG) and the central motor evoked potential (MEP) study.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.

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 the services. Our reviewer says that the enrollee does not have a reasonable indication for EMG. This was done as a stand-alone service, without a nerve conduction study performed. It's not otherwise clear that testing was done for an indication that is coverable. Additionally, given that the surgery took place below the termination of the spinal cord, the cord itself would not have been considered to have been at risk during the procedure. Consequently, the need/indication for performance of MEPs is otherwise unclear and this service cannot be adjudged to have been reasonable and necessary.

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 electromyography (EMG) and the entral motor evoked potential (MEP) study have not been met. Therefore, we decided that the Plan does not have to pay for the electromyography (EMG) and the central motor evoked potential (MEP) study.

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.