Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886 and 95909. We decided that the Plan does not have to pay for 
95822 and 95999.  
 
You asked the Plan to pay for neurology services (procedure codes 95822, 95886, 95909, 95999) provided to 
the enrollee on February 16, 2022.. You say that this should be paid for. The Plan says that the denied codes are 
not supported by the medical records submitted. 
 
The definition of the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
 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) 
 
CPT 95909: 
 
Nerve conduction studies; 5-6 studies 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
We decided that the Plan has to pay for 95886 and 95909.  
 
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 physician 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 95886 and CPT 95909. Our reviewer says that 
for CPT 95886, the technical report noted that the EMG had recording sites of abductor hallucis S1-S2, 
gastrocnemius L5-S1, tibialis anterior L4-S1, vastus lateralis L2-L4, and vastus medialis L2-L4. This verifies 
that 5 muscles were studied. Therefore, the records do support that CPT 95886 was rendered. In terms of CPT 
95909, the technical report noted that the nerve conduction tests pedicle screws were placed at the bilateral L4, 
L5, and S1. As the sites were bilateral, 6 sites were recorded. Therefore, the records do support that CPT 
95909: nerve conduction studies, 5-6 studies were rendered. 
 
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 
95886 and 95909.  
 
We also decided that the Plan does not have to pay for 95822 and 95999. 
 
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 physician 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 95822 and 95999. Our reviewer says that for 
CPT 95822, this code is not supported as the enrollee was not in a coma or sleep. There are more appropriate 
codes to use in this clinical scenario, such as CPT 95812 and CPT 95813. In terms of CPT 95999, the technical 
report noted that a train of four was utilized to assess the presence of neuromuscular blockade. The CPT code 
95999 was billed for this procedure. However, train-of-four monitoring is considered integral to intraoperative 
neuromonitoring and/or administration of anesthesia and, therefore, is not separately reportable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95822 and 95999 have not been met. Therefore, we decided that the Plan does 
not have to pay for 95822 and 95999. 
 
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.