Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 51785, 95822, 95927, and 95861. We decided that the Plan does not 
have to pay for 95937.  
 
You asked the Plan to pay for procedure codes 51785, 95822, 95861, 95927, 95937 provided to the enrollee on 
April 25, 2022.. You say that this should be paid for. The Plan says that the records do not support the services 
billed. 
 
The definition of the denied codes is: 
 
CPT 51785: 
 
Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 
 CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95927: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in the trunk or head 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
We decided that the Plan has to pay for 51785, 95822, 95927, and 95861.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 51785, 95822, 95927, and 95861. Our 
reviewer says that CPT 51785 is supported as the documentation shows the report for the anal sphincter 
electromyography (EMG). The records do support the use of CPT 95822 as the results of electroencephalogram 
(EEG) were given in the documentation. The medical records also support CPT 95927, as the documentation 
shows the upper and lower somatosensory evoked potentials (SSEP)s were performed and the test results 
given. Finally, the records support CPT 95861 as the detailed procedure was laid out in the records with the 
lower needle EMG and the upper/lower motor evoked potentials (MEPs). 
 
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 
51785, 95822, 95927, and 95861.  
 
We also decided that the Plan does not have to pay for 95937. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 95937. Our reviewer says that there is no 
documentation regarding neuromuscular junction testing. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95937. 
 
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.