Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forvarious neurology services provided to the enrollee on February 18, 2019.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the denied codes are not supported in the medical records submitted.The Plan must follow 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 the denied codes is:CPT 95955:electroencephalogram (EEG) during nonintracranial surgery (carotid surgery)CPT 95886:complete needle electromyography, per each extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more spinal levels (listed separately in addition to code for primary procedure)CPT 95910:nerve conduction studies; for 7-8 studiesCPT95887:needle electromyography of a non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (listed separately in addition to code for primary procedure)CPT 95999:unlisted neurological or neuromuscular diagnostic procedure  We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found the technical report in the medical records provided do not include documentation of an electroencephalogram (EEG) during nonintracranial surgery (carotid surgery), therefore, CPT 95955 cannot be validated as being performed on February 18, 2019. The medical records note that a real time EEG monitoring was performed, which is not covered by CPT code 95955. The technical report in the medical records provided does not include documentation of a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure), therefore CPT 95886 cannot be validated as being performed on February 18, 2019. The medical record indicates pedical screw or direct root stimulation was performed. This procedure does not meet the definition associated with CPT 95886, therefore, CPT 95886 should not be billed for this procedure. The technical report in the medical records provided does not include documentation on a nerve conduction studies; for 7-8 studies,therefore CPT 95910 cannot be validated as being performed on Februray 18, 2019. The use of pedical screws, as noted in the medical record, does not meet definition criteria for CPT code 95910. The technical report included in the medical records submitted does not include documentation of a needle electromyography of a non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (listed separately in addition to code for primary procedure) being performed on February 18, 2019. The medical record indicates pedical screw or direct root stimulation was performed. This procedure does not meet the definition associated with CPT 95887, therefore, CPT 95887 should not be billed for this procedure. The medical records provided do not include documentation of an unlisted neurological or neuromuscular diagnostic procedure (CPT 95999) being performed on February 8, 2019, there this service cannot be verified. The operative report indicates that Train of Four Testing was performed. Train of Four Testing is inclusive to the IONM, whether the IONM is primarily EMG based or MEP based. There is no CPT code available for use for Train of Four Monitoring, therefore is is inappropriate to use CPT 95999 for Train of Four Monitoring.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 not been met.Therefore, we decided that the Plan does not have to pay forvarious neurology services provided to the enrollee on February 18, 2019.