Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 95955, 95938, 95885 and 95908 
provided on September 22, 2021. 
 
You asked the Plan to pay for the medical services as billed. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation does 
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 billed codes are as follows: 
 
95955 -  Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  
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  
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)  
95908 -  Nerve conduction studies; 3-4 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 the medical services as billed. Our reviewer says that the 
documentation does not support the services as billed. Our reviewer found the following:  
 
CPT 95908  The technical report describes pedicle screw stimulation, which would not be reported with nerve 
conduction studies where amplitude and latency/velocity is measured. This procedure was incorrectly reported.  
 
CPT 95955  The technical report does not include documentation of Electroencephalogram (EEG) during 
nonintracranial surgery (eg, carotid surgery).  Procedure documents "continuous monitoring", no additional 
EEG testing was documented. Documentation and Coding Guidelines for Intraoperative Neurophysiology 
Monitoring (IONM) | USC Office of Culture, Ethics and Compliance 
 
CPT 95938  The technical report does not describe SSEP peripheral nerves or skin sites, recording from the 
central nervous system; upper and lower limbs.  To cite the technical report; "Bilateral Ulnar Nerve SSEP 
baselines were reproducible and reliable. There were no significant changes in either the latency (10%) or 
amplitude (50%) from baselines throughout the case. Surgeon advised and acknowledged. Bilateral Posterior 
Tibial Nerve SSEP baselines were reproducible and reliable. There were no significant changes in either the 
latency (l0%) or amplitude (50%) from baselines throughout the case. Surgeon advised and acknowledged."  
Per NCCI Policy Manual "the physician uses somatosensory-evoked potential to provide information about the 
integrity of the peripheral nerves, spinal cord, brain stem, and the cortex. Evoked potentials require low 
voltages and the placement of electrodes on the scalp near the parts of the nervous system where the signals are 
generated. The physician may place electrical stimulation at the median nerve of the wrist or the posterior tibial 
nerve at the ankle, or the physician may stimulate points between these and the central nervous system. Many 
applications may be necessary to screen background noise to measure the interval between stimulation and the 
generated response".  Therefore, this procedure cannot be verified. 
 
CPT 95885 - As per CPT code description, this procedure is done with nerve conduction studies. Technical 
report does not support nerve conduction studies, and therefore this procedure would not be covered. 
 
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 medical services as billed have not been met. Therefore, we decided that the 
Plan does not have to pay for the medical services coded 95955, 95938, 95885 and 95908 provided on 
September 22, 2021.