Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for testing services described by procedure codes 95861, 2 units, 
defined as needle electromyography; 2 extremities with or without related paraspinal areas, 95999, 1 unit, 
defined as unlisted neurological or neuromuscular diagnostic procedure, and 95870, 2 units, defined as 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, performed on date of service 
August 2, 2022. 
 
You asked the Plan to pay for testing services coded as 95861, 95999, and 95870. You say that 2 units of code 
95861 were medically necessary and billed accurately. You say that 95999 and 95870 are also accurate and 
supported in the records. The Plan denied your request. The Plan says two units of code 95861 were denied 
because the provider has not documented any medically necessary reason for performing extra units in excess 
of the 1 allowed. The Plan says codes 95999 and 95870 are denied because they are not supported in the 
records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules say that submitted claims in 
which the unit of service exceeds the MUE value cannot be paid when the MAI value is 3, unless there is 
evidence justifying the excess units. 
 
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 testing services. Our reviewer says that 2 units of code 95861 
are not supported in the record. Code 95999 is also not supported in the record.  Our reviewer found that 
regarding 95861, the record states that the needle electromyography (EMG) was performed on the bilateral 
lower extremities and related paraspinal areas, which equals 1 unit of 95861. Regarding 95999, the record 
states that this code was used to report train of four testing. According to CPT rules, train of four is included in 
intraoperative neuromonitoring services and is not separately reportable with an unlisted code.  
 
We looked at this coder's review, the file, and Medicare rules. Our coder indicated that records show 1 needle 
EMG was performed on the bilateral lower extremities and related paraspinal areas and that procedure 
represents 1 unit of 95861. This means that code 95870 is not supported in the record as required, therefore 
does not meet Medicare guidelines. Based on this information, we decided that Medicare rules for coverage of 
testing services have not been met. Therefore, we decided that the Plan does not have to pay for testing services 
described by procedure codes 95861, 2 units, defined as needle electromyography; 2 extremities with or 
without related paraspinal areas, 95999, 1 unit, defined as unlisted neurological or neuromuscular diagnostic 
procedure, and 95870, 2 units, defined as 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, performed on date of service August 2, 2022.