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 
95955.  
 
You asked the Plan to pay for neurology services (procedure codes 95886, 95909, 95955) provided to the 
enrollee on June 14, 2022.. You say that this should be paid for. The Plan says that the records do not support 
the services billed. 
 
 
 
 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. The definition of these 
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 95909: 
 
Nerve conduction studies; 5-6 studies 
 
Our reviewer says that the records support that CPT 95886 was rendered in this case. The technical report cites 
the lower EMG (electromyography) has recording sites, bilateral lower extremities, of abductor 
hallucis/abductor digiti minimi; gastroc; peroneus longus; rectus femoris; and tibialis anterior. This 
corroborates that 5 or more muscles were studied for this procedure. Additionally, CPT 95909 is supported to 
have been rendered in this case. The technical report cites pedicle testing was recorded at the bilateral L4, L5, 
and S1. This is 3 sites performed bilaterally for 6 studies. 
 
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 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 95955. The definition of this code is 
"Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)." Our reviewer says that  
Our physician reviewer found   
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95955 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95955. 
 
 
 
 
 
 
 
 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.