Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology services (95955, 95885, 95937, 95927, and
95907) provided on June 30, 2021.

You asked the Plan to pay for codes 95955, 95885, 95937, 95927, and 95907. You say that the medical records
support the billing of codes 95955, 95885, 95937, 95927, and 95907 provided on June 30, 2021. The Plan
denied your request. The Plan says the medical records do not support the billing of codes 95955, 95885,
95937, 95927, and 95907 provided on June 30, 2021.

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 95955 is Electroencephalogram (EEG) during
nonintracranial surgery (eg, carotid surgery). The definition of code 95885 is Needle electromyography, each
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and
latency/velocity study; limited (List separately in addition to code for primary procedure). The definition of
code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1
method. The definition of code 95927 is Short-latency somatosensory evoked potential study, stimulation of
any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head. The
definition of code 95907 is Nerve conduction studies; 1-2 studies.

We asked our coder 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 codes 95955, 95885, 95937, 95927, and 95907. Our reviewer
says that the medical records do not support the billing of codes 95955, 95885, 95937, 95927, and 95907
provided on June 30, 2021. Our reviewer found code 95955 is inappropriate to report for "real time"
monitoring. There is a more appropriate HCPCS/CPT code to report, and any additional EEG would be
included in the correct procedure code. Per CPT description, code 95885 is performed with nerve conduction
studies, as nerve conduction studies are not documented, this procedure would not be covered. For code 95937,
the documentation describes Train of Four testing was performed, and reported with Neuromuscular junction
testing. No code exists for Train of Four testing, as this procedure is included in the primary neuromonitoring
code and should not be reported separately. For code 95927, the documentation documents Ulnar nerve
stimulation at Erb's point. This is the incorrect code to report for SSEP in the trunk or head. Procedure
documented is inclusive to SSEP ulnar nerve. For code 95907, the documentation does not document nerve
conduction studies to include amplitude, latency and conduction velocity measurement. The documentation
supports Pedicle screw stimulation which would not be reported for nerve conduction studies.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of codes 95955, 95885, 95937, 95927, and 95907 have not been met. Therefore,
we decided that the Plan does not have to pay for the neurology services (95955, 95885, 95937, 95927, and
95907) provided on June 30, 2021.