Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886, 95937, and 95955. We decided that the Plan does not have to 
pay for 95908.  
 
You asked the Plan to pay for neurology services (procedure codes 95886, 95908, 95937, 95955) provided to 
the enrollee on February 3, 2022. You say that this should be paid for. The Plan says that the records do not 
support the services billed. 
 
The definition of the denied codes is: 
 
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 95908: 
 
Nerve conduction studies; 3-4 studies 
 
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 decided that the Plan has to pay for 95886, 95937, and 95955.  
 
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, 95937, and 95955. Our reviewer says 
that the records support that CPT 95886 was rendered in this case. The technical report stated the lower EMG 
(electromyography) had recording sites of abductor hallucis, tibialis anterior, vastus lateralis, vastus medialis, 
and extensor hallucis longus. 
 
The records also support that CPT 95937 was rendered in this case. The intraoperative monitoring stated 
pedicle testing was performed at the bilateral L3, L4, and L5. 
 
Finally, the records support that CPT 95955 was rendered in this case. The technical report did corroborate that 
an electroencephalogram was performed during the procedure. 
 
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, 95937, and 95955.  
 
We also decided that the Plan does not have to pay for 95908. 
 
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 95908. Our reviewer says that the 
intraoperative monitoring included a somatosensory evoked potential (SSEP), lower electromyography, pedicle 
testing, electroencephalogram, and train of four monitoring. There is no indication of any nerve conduction 
studies performed. Therefore, the records do not support the use of CPT 95908 in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95908 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95908. 
 
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.