Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure codes 95955, 95885, 95907, 95937, and 95927.  You asked the Plan to pay for procedure codes 95955, 95885, 95907, 95937, and 95927. You say that [you have provided medical records to support payment of these codes.  The Plan denied your request. The Plan says these codes cannot be verified  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 definitions of the denied codes are as follows:  Code 95955: Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery); Code 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);  Code 95907: Nerve conduction studies;1-2 studies;   Code 95937:  neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method;   Code 95927:  Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the trunk or head.  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 procedure codes 95955, 95885, 95907, 95937, and 95927. Our reviewer says that the billing of these procedure codes is not supported by the medical record. Our reviewer found that for code 95955, the medical records provided do not include sufficient documentation to validate that an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) was performed on November 4, 2020; so this service cannot be verified as real time EEG monitoring is not covered by CPT 95955.  For code 95885, our reviewer found that the medical records provided do not document that a limited needle electromyography with nerve conduction was performed on November 4, 2020.  The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, so this service cannot be verified. For code 95907, our reviewer found that the medical records provided do not document that a nerve conduction study of 1-2 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95907.  For code 95937, our reviewer found that the medical records submitted document Train of Four testing, which does not meet the coding definition of CPT 95937, therefore, this service cannot be verified. Finally, our reviewer found that for code 95927, the medical records do not include sufficient documentation to validate that 95927 was performed as a distinct/separate service from the somatosensory evoked potentials of the ulnar nerve performed during the same operative session on November 4, 2020  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of procedure codes 95955, 95885, 95907, 95937, and 95927 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 95955, 95885, 95907, 95937, and 95927.