Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95861. We decided that the Plan does not have to pay for 51785 and 
95870.  
 
You asked the Plan to pay for neurology services provided to the enrollee on April 13, 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 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. In this case, the CPT Code Manual definition of 
CPT 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 for CPT 95861. Our physician reviewer found that the 
records provided for review did demonstrate that that free running electromyography (EMG) was performed in 
the bilateral lower extremities during the procedure. The records and screen shots demonstrate the performance 
of such 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 [Description of Favorable Item/Service] have been met. Therefore, we decided 
that the Plan has to pay for 95861.  
 
We also decided that the Plan does not have to pay for 51785 and 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 the remaining denied codes is: 
 
CPT 51785: 
 
Needle electromyography studies (EMG) of anal or urethral sphincter, any technique 
 
CPT 95870: 
 
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 51785 and CPT 95870. Our physician 
reviewer found that according to coding guidelines for CPT 51785, the physician places a pad or needle in the 
anal or urethral sphincter and measures the electrical activity with the bladder filled and during emptying. 
There were no such measurements performed during the surgery. Rather, there was simply free running EMG, 
with no measurements. This would not meet the requirements for this code. In terms of CPT 95870, there was 
no indication in the records that demonstrated that the denied code was rendered in this case. The records 
suggest instead that this code was used for motor evoked potential, which has its own distinct CPT code. This 
would not have been supported. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 51785 and 95870 have not been met. Therefore, we decided that the Plan does 
not have to pay for 51785 and 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.