Appeal type: Testing
Decision: Partially Favorable

We decided that the Plan has to pay for code 95861. We decided that the Plan does not have to pay for codes 95955, 95937, 95927, and 95908.
You asked the Plan to pay for the services. You say that the medical records support the billing of codes 95955, 95861, 95937, 95927, and 95908. The Plan says that the medical records do not support the billing of codes 95955, 95861, 95937, 95927, and 95908.
We decided that the Plan has to pay for code 95861.
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 95861 is Needle electromyography; 2 extremities with or without related paraspinal areas. 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 payment of code 95861. Our reviewer says that the medical records support the billing of code 95861. Our physician reviewer found free running EMG were noted to have been recorded in both lower extremities during surgery. The code as used in this case would therefore have been met/satisfied. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 95861 have been met. Therefore, we decided that the Plan has to pay for code 95861.
We also decided that the Plan does not have to pay for codes 95955, 95937, 95927, and 95908.
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 95955 is Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). The definition of code 95937 is Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The definition of code 95927 is 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 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 payment of codes 95955, 95937, and 95927. Our reviewer says that the medical records do not support the billing of codes 95955, 95937, and 95927. Our physician reviewer found code 95955 is not supported. There was only a limited EEG performed (2 channels). This falls well below the minimum number of channels needed for recording of an EEG based on ACNS technical standards. The use of a two channel EEG is otherwise essentially non-diagnostic in nature (secondary to a lack of pertinent clinical information). This would not have been coded properly. Code 95937 was not used properly. A peripheral nerve stimulator, also known as a train-of-four monitor, is used to assess neuromuscular transmission when neuromuscular blocking agents are given to block musculoskeletal activity. By assessing the depth of neuromuscular blockade, peripheral nerve stimulation can ensure proper medication dosing and, thus, decrease the incidence of side effects. Train-of-four monitoring is bundled with the intraoperative neuromonitoring of electromyography (EMG) or motor evoked potentials (MEP) and, therefore, is not separately reportable. Code 95927 is not supported. The stimulation done of SSEPs was only performed in the extremities. There would have been another CPT code that could have been used to better represent this service/the service provided.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95955, 95937, and 95927 have not been met. Furthermore, we have confirmed that code 95908 is a column II code to column I code 95861. These codes should not be reported together. Therefore, we decided that the Plan does not have to pay for codes 95955, 95937, 95927, and 95908.
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.