Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the digital analysis of an electroencephalogram (95957), nerve conduction studies (95908), needle electromyography (95886) and the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on October 27, 2020.  You asked the Plan to pay for the digital analysis of an electroencephalogram, nerve conduction studies, needle electromyography and the unlisted neurological or neuromuscular diagnostic procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted 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.  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 digital analysis of an electroencephalogram, nerve conduction studies, needle electromyography and the unlisted neurological or neuromuscular diagnostic procedure. Our reviewer says that CPT codes 95908 and 95908 do not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to support that a Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) was performed on October 27, 2020, therefore this procedure cannot be verified. The medical records provided do not include sufficient documentation to support that a Nerve conduction studies; 3-4 studies as pedicle screw stimulations are not baseline nerve conduction studies.  Therefore, this service cannot be verified. Our reviewer found CPT codes 95886 and 95999 do not meet criteria for billing or reimbursement consideration. The medical records provided do not include sufficient documentation to support that a  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) was performed on October 27, 2020 as pedicle screw stimulations do not meet criteria of baseline nerve conduction studies. The medical records provided indicates Train Of Four Testing was performed which is not covered by CPT code 95999, therefore this service cannot be verified.  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 digital analysis of an electroencephalogram, nerve conduction studies, needle electromyography and the unlisted neurological or neuromuscular diagnostic procedure have not been met. Therefore, we decided that the Plan does not have to pay for the digital analysis of an electroencephalogram (95957), nerve conduction studies (95908), needle electromyography (95886) and the unlisted neurological or neuromuscular diagnostic procedure (95999) provided on October 27, 2020.