Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for neuromuscular junction testing (repetitive stimulation, paired 
stimuli), each nerve, any 1 method (CPT code 95937-26-59), needle electromyography, each extremity, with 
related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; 
limited (95885-26), nerve conduction studies; 3-4 studies (95908-26-59), needle EMG studies of anal or 
urethral sphincter, any technique (51785-26) and EEG during nonintracranial surgery (eg, carotid surgery 
(95955-26-59) provided on March 22, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 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 services. Our reviewer found the review indicates that 
Procedure code 95937-26-59 is not supported by the medical records submitted. The technical report did not 
include documentation of neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, 
by any 1 method; therefore, this code cannot be verified. Procedure code 95885-26 is not supported by the 
medical records submitted. The technical report did not include documentation of a limited needle 
electromyography, per each extremity with related paraspinal areas when performed, done with nerve 
conduction, amplitude and latency/velocity study; (listed separately in addition to code for primary procedure); 
therefore, this code cannot be verified. Procedure code 95908-26-59 is not supported by the medical records 
submitted. The technical report did not include documentation of nerve conduction studies, for 3-4 studies; 
therefore, this code cannot be verified. Procedure code 51785-26 is not supported by the medical records 
submitted. The technical report did not include documentation of needle EMG studies of anal or urethral 
sphincter, using any technique; therefore, this code cannot be verified. Per the National Correct Coding 
Initiative Policy Manual for Medicare Services, Revision Date: January 1, 2021; in regards to the submitted 
CPT code of 95955-26-59, the physician places sensors on a patient's head in an EEG to measure and record 
the brain's electrical activity. This code applies to an EEG during surgery exclusive of surgery to the brain. This 
description was not documented in the operate report narrative.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 
method (CPT code 95937-26-59), needle electromyography, each extremity, with related paraspinal areas, 
when performed, done with nerve conduction, amplitude and latency/velocity study; limited (95885-26), nerve 
conduction studies; 3-4 studies (95908-26-59), needle EMG studies of anal or urethral sphincter, any technique 
(51785-26) and EEG during nonintracranial surgery (eg, carotid surgery (95955-26-59) provided on March 22, 
2021.