Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (eg, for
epileptic spike analysis) (95957) neuromuscular junction testing (repetitive stimulation, paired stimuli) each
nerve, any one method (95937) nerve conduction studies 5-6 studies (95909) 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) (95886) provided June 15, 2021.
You asked the Plan to pay for the intraoperative monitoring services. You say that it is your position that your
service codes were billed correctly and that the CPT codes utilized are correct for the type of service
performed. The Plan denied your request. The Plan says the records provided do not support the billed service.
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 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 intraoperative monitoring services. Our reviewer says
that the requested items/services are not supported in the medical records. Our reviewer found the medical
records provided does not include sufficient documentation to validate that a digital analysis of
electroencephalogram (EEG) (eg. for epileptic spike analysis). The medical records indicate that real time
electroencephalogram monitoring was performed, which in not covered under CPT 95957. The medical records
provided does not include sufficient documentation to validate that neuromuscular junction testing (repetitive
stimulation, paired stimuli, each nerve, any 1 method was performed. The medical records submitted indicate
Train of Four (TOF) testing was performed. Train of Four testing is not represented by CPT 95937 therefore it
is inappropriate to use 95937 to bill for TOF testing as is considered inclusive to the IONM and should not be
billed separately. The medical records provided does not include sufficient documentation to validate that a
nerve conduction study; 5 - 6 studies was performed. The medical records indicate the use of pedicle screws
which are not baseline nerve conduction studies and are not covered under CPT code 95909. The medical
records provided does not include sufficient documentation to validate that a needle electromyography, each
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and
latency/velocity study; complete 5 or more muscles studied, innervated by 3 or more nerves or four or more
spinal levels, (List separately in addition to code for primary procedure) was performed. The medical records
indicated the use of pedicle screws, which are not baseline nerve conduction studies and are not covered under
CPT code 95909, therefore the nerve conduction study cannot be verified, which is necessary in order to meet
the coding criteria for CPT 95886.
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 intraoperative monitoring services have not been met. Therefore, we
decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) (eg, for epileptic
spike analysis) (95957) neuromuscular junction testing (repetitive stimulation, paired stimuli) each nerve, any
one method (95937) nerve conduction studies 5-6 studies (95909) 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) (95886) provided June 15, 2021.