Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95938 and 95939. We decided that the Plan does not have to pay for 
959907 and 95886.  
 
You asked the Plan to pay for neurology services provided to the enrollee from November 22, 2021.. You say 
that this should be paid for. The Plan says that the provider should bill the facility. 
 
The definition of the denied codes is: 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 studies 
 
CPT 95938: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in upper and lower limbs 
 
CPT 95939: 
 
Central motor evoked potential study (transcranial motor stimulation); in upper and lower limbs 
 
CPT 95886: 
 
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) 
 
We decided that the Plan has to pay for 95938 and 95939.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 95938 and 95939. Our reviewer says that the 
provider is a remote neuromonitoring provider, which supplies the equipment, technologist, and qualified 
healthcare professional to provide neuromonitoring services, and should not be included in the Diagnosis 
Related Group (DRG) payment. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
95938 and 95939.  
 
We also decided that the Plan does not have to pay for 959907 and 95886. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We asked our coder reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request for CPT 95907 and 95886. Our reviewer says that 
although these codes should also not be included in the DRG payment, the records still do not support their use. The procedure report does not support nerve conduction studies, which measure amplitude and 
latency/velocity, when pedicle screw stimulation is performed. Pedicle screw stimulation should not be 
reported with nerve conduction studies. Nerve conduction studies cannot be verified; therefore, these 
procedures would not be covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 959907 and 95886 have not been met. Therefore, we decided that the Plan does 
not have to pay for 959907 and 95886. 
 
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.