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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say that it is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Nerve Conduction Studies and Electromyography (A54095) - Effective October 1, 2021. 

The rules say that it is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted. You can find this rule in the Local Coverage Article (LCA) - Billing and Coding: Intraoperative Neurophysiological Testing (A57604) - Effective October 1, 2020. 

The rules say that a few prime examples in electromyography (EMG) may be helpful, although not an all-inclusive listing, are disc disease producing spinal nerve dysfunction, advanced nerve compression in peripheral lesions, Amyotrophic Lateral Sclerosis (ALS), and polyneuropathy, etc. After an acute neurogenic lesion, it is important to note that EMG changes may not appear for several days to weeks in the innervated muscles. Below is a list of common disorders where an EMG, in tandem with properly conducted NCS, will be helpful in diagnosis: 

1. Nerve compression syndromes, including carpal tunnel syndrome and other focal compressions 
2. Radiculopathy - cervical, lumbosacral 
3. Mono/polyneuropathy - metabolic, degenerative, hereditary 
4. Myopathy - including poly-and dermatomyositis, myotonic and congenital myopathies 
5. Plexopathy - idiopathic, trauma, infiltration 
6. Neuromuscular junction disorders - myasthenia gravis. Single fiber EMG is of special value here 
7. At times, immediately prior to Botulinum A toxin injection, for localization 
8. At times, immediately prior to injection of phenol or other substances for nerve blocking or chemodenervation There may be other instances, not detailed here, where EMG may be of use. 

You can find this rule in the Local Coverage Determination (LCD) - Nerve Conduction Studies and Electromyography (L35081) - Effective October 31, 2019.

The rules say that some high-risk patients may be candidates for a surgical procedure only if monitoring is available. To establish medical necessity, certain guidelines must be followed. Intraoperative testing may be indicated with the following types of surgery: 

1. Surgery of the aortic arch, its branch vessels, or thoracic aorta, including internal carotid artery surgery, when there is risk of cerebral ischemia 
2. Resection of epileptogenic brain tissue or tumor 
3. Resection of brain tissue close to the primary motor cortex and requiring brain mapping 
4. Protection of cranial nerves
 
a. Resection of tumors involving the cranial nerves 
b. Cavernous sinus tumors 
c. Microvascular decompression of cranial nerves 
d. Skull base surgery in the vicinity of the cranial nerves and surgeries of the foramen magnum 
e. Oval or round window graft 

5. Endolymphatic shunt for Meniere's disease 
6. Vestibular section for vertigo 
7. Correction of scoliosis or deformity of spinal cord involving traction on the cord 
8. Protection of spinal cord where work is performed in close proximity to cord as in the removal of old hardware or where there have been numerous interventions 
9. Spinal instrumentation requiring pedicle screws or distraction 
10. Decompressive procedures on the spinal cord or cauda equina carried out for myelopathy or claudication where function of spinal cord or spinal nerves is at risk 
11. Spinal cord tumors and spinal fractures (with the risk of cord compression) 
12. Neuromas of peripheral nerves or bracial plexus, when there is risk to major sensory or motor nerves 
13. Surgery or embolization for intracranial arteriovenous (AV) malformations 
14. Surgery for arteriovenous malformation of spinal cord 
15. Embolization of bronchial artery AVMs or tumors 
16. Cerebral vascular aneurysms 
17. Surgery for intractable movement disorders 
18. Arteriography, during which there is a test occlusion of the carotid artery 
19. Circulatory arrest with hypothermia (does not include surgeries performed under circulatory bypass [e.g., CABG, ventricular aneurysms]) 
20. Distal aortic procedures, where there is risk of ischemia to spinal cord 
21. Leg lengthening procedures, where there is traction on sciatic nerve or other nerve trunks 
22. Basal ganglia movement disorders 
23. Surgery as a result of traumatic injury to spinal cord/brain 
24. Deep brain stimulation, and 
25. Certain thyroid surgeries 

You can find this rule in the Local Coverage Determination (LCD) - Intraoperative Neurophysiological Testing (L35003) - Effective November 14, 2019.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.