Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for  95861-26. We decided that the Plan does not have to pay for  95861-
26-XU.  
 
You asked the Plan to pay for  testing services provided on August 25, 2022, billed with procedure codes 
95861-26 and 95861-26-XU. You say that the claim is billed correctly and should be paid. The Plan says that 
the number of units billed exceeds the maximum allowed.  
 
We decided that the Plan has to pay for  95861-26.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
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 to pay for the item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that the enrollee 
underwent lumbar surgery, for which neurophysiology monitoring was performed. Electromyography's (EMG) 
of the bilateral lower extremities were performed. The physician interpreted the monitoring from a remote 
location but did not perform the procedure. There is no evidence that services were provided twice. As such the 
billing of a second unit of 95861, as 95861-26-XU is not 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 the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for  95861-26.  
 
We also decided that the Plan does not have to pay for  95861-26-XU. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
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 to pay for the item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that the enrollee 
underwent lumbar surgery, for which neurophysiology monitoring was performed. Electromyography's (EMG) 
of the bilateral lower extremities were performed. The physician interpreted the monitoring from a remote location but did not perform the procedure. There is no evidence that services were provided twice. As such the 
billing of a second unit of 95861, as 95861-26-XU is not 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 the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for  95861-26-XU. 
 
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.