Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology services (95885, 95907, and 95937) provided
on July 21, 2021.
You asked the Plan to pay for codes 95885, 95907, and 95937. You say that the medical records support the
billing of codes 95885, 95907, and 95937 provided on July 21, 2021. The Plan denied your request. The Plan
says the medical records do not support the billing of codes 95885, 95907, and 95937 provided on July 21,
2021.
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 definition of code 95885 is 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). The definition of code 95907 is Nerve
conduction studies; 1-2 studies. The definition of code 95937 is Neuromuscular junction testing (repetitive
stimulation, paired stimuli), each nerve, any 1 method.
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 codes 95885, 95907, and 95937. Our reviewer says that the medical records do not support the billing of codes 95885, 95907, and 95937 provided on July 21, 2021. Our reviewer found the medical records provided does not include sufficient documentation to validate that Neuromuscular junction testing (repetitive stimulation, paired stimuli, each nerve, any 1 method was performed on July 21, 2021. The medical records submitted indicate Train of Four (TOF) testing was performed. Train of Four testing is not represented by CPT 95937; therefore, it is inappropriate to use 95937 to bill for TOF testing as is is considered inclusive to the IONM an should not be billed separately. The medical records provided does not include sufficient documentation to validate that a Nerve conduction study; 1-2 studies was performed on July 21, 2021. The medical records indicate the use of pedicle screws which are not baseline nerve conduction studies and are not covered under CPT code 95907, therefore CPT 95907 cannot be verified. The medical records provided does not include sufficient documentation to validate that a 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) was performed on July 21, 2021. The medical records indicated the use of pedicle screws, which are not baseline nerve conduction studies and are not covered under CPT code 95907, therefore the Nerve conduction study cannot be verified, which is necessary in order to meet the coding criteria for CPT 95885. As a result, CPT 95885 is not payable. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95885, 95907, and 95937 have not been met. Therefore, we decided that the Plan does not have to pay for the neurology services (95885, 95907, and 95937) provided on July 21, 2021.