Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography (95886), nerve conduction studies (95907), electroencephalogram (95955) and unlisted neurological procedure (95999) provided on March 1, 2021.  You asked the Plan to pay for the needle electromyography, nerve conduction studies, electroencephalogram and unlisted 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 needle electromyography, nerve conduction studies, electroencephalogram and unlisted procedure. Our reviewer says that CPT code 95886 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation of 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) being performed on March 1, 2021, as the medical records do not include documentation that a nerve conduction study was performed, which is required to meet CPT definition of 95886.  Therefore, this service cannot be verified.  CPT code 95907 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that a nerve conduction studies; 1-2 studies was performed on March 1, 2021, therefore, this service cannot be verified.    CPT code 95955 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) was performed on March 1, 2021, as a real time EEG is not covered under CPT 95955; therefore this service cannot be verified.   Our reviewer found CPT code 95999 does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation of an unlisted neurological or neuromuscular diagnostic procedure on March 1, 2021, therefore this procedure cannot be verified. The medical records indicate train of four testing was done, which is included inclusive when performed during intraoperative neurophysiological monitoring and is not eligible for additional reimbursement. Also, 95999 in an unlisted procedure and no lay description available.  In order to bill 95999 the operative note must include specific documentation that describes or indicates the procedure that is being billed under code 95999.  There was no such description documented in the operative note.  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 needle electromyography, nerve conduction studies, electroencephalogram and unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95886), nerve conduction studies (95907), electroencephalogram (95955) and unlisted neurological procedure (95999) provided on March 1, 2021.