Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95940. We decided that the Plan does not have to pay for G0453.   
You asked the Plan to pay for procedure codes G0453 and 95940 rendered on April 19, 2023.. 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 95940.  
 
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 CPT 95940 is "Continuous 
intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal 
attendance, each 15 minutes (List separately in addition to code for primary procedure)." 
 
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 95940. Our reviewer says that CPT 95955 
would not be reported for a posterior spinal fusion L4 - L5, transforaminal lumbar interbody fusion (TLIF) L4 - 
L5.  CPT 95940 would be appropriate code to report for service provided. 
 
We looked at this coder'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 
95940.  
 
We also decided that the Plan does not have to pay for G0453. 
 
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 HCPCS G0453 is "Continuous 
intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, 
(attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)." 
 
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 G0453. Our reviewer says that while CPT codes 
95940 and G0453 may be reported for sequential non-overlapping time periods, such as when the provider 
begins monitoring in the operating room and then moves outside the operating room for remote monitoring, 
these codes may not be reported for concurrent time periods. The procedure report does not support modifier 
59 distinct procedural service, and therefore this was denied correctly as an unbundled service. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of G0453 have not been met. Therefore, we decided that the Plan does not have to 
pay for G0453. 
 
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.