Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 95939, 95938, 95957, 
95908, 95886, 95887, and G0453. We decided that the Plan does not have to pay for the services described by 
procedure code 95937.  
 
You asked the Plan to pay for the neurophysiology services described by codes 95939, 95938, 95957, 95908, 
95886, 95887, G0453, and 95937 performed on June 12, 2023. You say that 95939, 95938, 95957, 95908, 
95886, 95887, G0453, and 95937 should be paid as billed because these services are supported in the 
documentation and were medically necessary. The Plan says that 95939, 95938, 95957, 95908, 95886, 95887, 
and G0453 are being handled as an original decision reopen, therefore no coverage decision has been made. 
95937 is denied because it is not supported in the documentation. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 95939, 95938, 95957, 
95908, 95886, 95887, and 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. 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) 95939, 95938, 95957, 95908, 
95886, 95887, and G0453.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 95937. 
 
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 95937 is neuromuscular junction testing (repetitive 
stimulation, paired stimuli), each nerve, any 1 method. 
 
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 the services described by procedure code 95937. Our 
reviewer says that 95937 is not supported in the documentation. Our reviewer found the medical record 
documents "for neuromuscular junction monitoring (train of four), electrical stimulation was applied to a 
peripheral nerve and recorded from the corresponding muscle in order to assess the level of neuromuscular 
blockade." It is not appropriate to bill separately for train-of-four (TOF) monitoring. The American Medical 
Association (AMA) has clearly stated that CPT code 95937 is not appropriate for this procedure. 
 
We looked at this coders 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) 95937 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code 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.