Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the needle electromyography (95886 and 95887), nerve 
conduction studies (95913) and digital analysis of an electroencephalogram (EEG)(95957) provided on March 
30, 2021. 
 
You asked the Plan to pay for the needle electromyography, nerve conduction studies and digital analysis of an 
EEG. 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. 
 
In this case, the CPT Code Manual definition of code 95886 is 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). 
 
The CPT Code Manual definition of CPT code 95887 is needle electromyography, non-extremity (cranial nerve 
supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study (List separately 
in addition to code for primary procedure). 
 
The CPT Code Manual definition of code 95913 is nerve conduction studies; 13 or more studies. 
 
The CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for 
epileptic spike analysis). 
 
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 and 
digital analysis of an EEG. Our reviewer says that CPT codes 95886, 95887 and 95913 do not meet criteria for 
billing or reimbursement consideration. The technical report describes pedicle screw stimulation, which would 
not be reported with nerve conduction studies procedure codes. Nerve conduction studies measure amplitude 
and latency/velocity, which is not documented in the technical report. CPT codes 95886 and 95887 are done 
with nerve conduction studies, which cannot be verified as performed. Our reviewer found CPT code 95957 
does not meet criteria for billing or reimbursement consideration. The technical report does not include 
documentation of Digital analysis of electroencephalogram (EEG). There is a more appropriate code that would 
be reported for baseline EEG, additional EEG testing would not be reported separately from the 
neruomonitoring procedure code. 
 
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 and digital analysis of 
an EEG have not been met. Therefore, we decided that the Plan does not have to pay for the needle 
electromyography (95886 and 95887), nerve conduction studies (95913) and digital analysis of an 
electroencephalogram (EEG)(95957) provided on March 30, 2021.