Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neurophysiology services provided to the enrollee on August 
11, 2021. 
 
You asked the Plan to pay for this should be paid for.. You say that this should be paid for. The Plan denied 
your request. The Plan says the records do not support the services billed. 
 
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 95885: 
 
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) 
 
CPT 95908: 
 
Nerve conduction studies; 3-4 studies 
 CPT 95927: 
 
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 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
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 this should be paid for. Our reviewer says that the services at 
issue in this case were not supported by the medical records.  
 
Our reviewer found that in terms of CPT 95885, this code was not supported in the records. Notably, there was 
not a nerve conduction study performed, as defined by the current standards. In terms of CPt 95908, a nerve 
conduction study involves recording from a surface electrode in response to electrical stimulation along a 
nerve. In this case the enrollee only underwent pedicle screw testing. This is otherwise considered (for coding 
purposes) to be part of the electromyography (EMG) monitoring service/procedure. There was no evidence that 
a formal diagnostic nerve conduction study was otherwise performed.  
 
In terms of CPT 95927, while somatosensory evoked potentials (SSEPs) were recorded in this case, the CPT 
code did not otherwise reflect the manner in which they were collected. Rather, the placement of electrodes in 
this case is under the category of CPT 95938.  
 
In terms of CPT 95937, neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 
1 method was not done. Rather, the service provided was "train of four" testing. Train-of-four monitoring is 
considered integral to intraoperative neuromonitoring and/or administration of anesthesia and is otherwise not 
considered to be a separately reimbursable service. Likewise, this testing was not done for diagnostic purposes 
as defined by the CPT manual.  
 
In terms of CPT 95955, the enrollee only underwent recording with a two channel electroencephalogram 
(EEG). This is below the minimum technical standards as defined by the American Clinical Neurophysiology 
Society (ACNS) for performance of EEG. A two channel EEG is otherwise only of potential use in monitoring 
depth of anesthesia (in which case it is integral to anesthesia services). As the records did not support that a 
minimally technically valid EEG had been done, this code cannot be said to have been supported. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of this should be paid for. have not been met. Therefore, we decided that the Plan 
does not have to pay for neurophysiology services provided to the enrollee on August 11, 2021.