Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forneuromuscular junction testing (95937), needle electromyography (95886, 95887), nerve conduction studies (95907), and an electroencephalogram (EEG) (95955) provided on February 12, 2020.You asked the Plan to pay forneuromuscular junction testing, needle electromyography, nerve conduction studies, and an EEG. You say that these codes are documented in the records.The Plan denied your request. The Plan says these codes are not supported.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 code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95886 is 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). The definition of code 95887 is n eedle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately in addition to code for primaryprocedure). The definition of code 95907 is nerve conduction studies; 1-2 studies.The definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery).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 neuromuscular junction testing, needle electromyography, nerve conduction studies, and an EEG. Our reviewer says that these codes are not supported in the records. Our physician reviewer found the medical records submitted document that CPT 95937 is being used to represent Train of four. Per CPT instructions, train of four, when performed during intraoperative neurophysiological monitoring (IONM), is inclusive to the IONM. Also, there is no specific code that is assigned to Train-of-Four testing. he medical records provided does not include documentatio of a complete needle electromyography done with nerve conduction. Pedicle screw stimulations are not baseline nerve conduction studies. There is a more appropriate billable CPT code for a complete EMG without nerve conduction studies. Therefore, CPT 95886 and CPT 95887 are not substantiated by the clinical documentation in the technical report submitted and cannot be verified. The records also do not support CPT 95907. Pedicle screw or direct root stimulations are not baseline nerve conduction studies which would include measurements of amplitude, latency, and conduction velocity, therefore, the requested procedure code is not substantiated in the operative narrative and 95907 cannot be verified. Finally, the medical records provided do not include documentation of an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) being performed on February 12, 2020, therefore, 95955 cannot be verified.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of neuromuscular junction testing, needleelectromyography, nerve conduction studies, and an EEG have not been met.Therefore, we decided that the Plan does not have to pay forneuromuscular junction testing (95937), needle electromyography (95886, 95887), nerve conduction studies (95907), and an electroencephalogram (EEG) (95955) provided on February 12, 2020.