Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886 and 95909. We decided that the Plan does not have to pay for 
95822 and 95999.  
 
You asked the Plan to pay for neurology imaging services provided to the enrollee on November 9, 2021.. You 
say that this should be paid for. The Plan says that the procedure codes are not supported by the medical 
records submitted. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 CPT 95886: 
 
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) 
 
CPT 95909: 
 
Nerve conduction studies; 5-6 studies 
 
CPT 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
We decided that the Plan has to pay for 95886 and 95909.  
 
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 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 CPT 95885 and 95909.  
 
Our reviewer says that in terms of CPT 95885, during the spinal fusion surgery, the technical report did support 
that there was an electromyography (EMG) performed. The lower EMG recording sites were noted as abductor 
hallucis, anal sphincter S2-S4, gastroc S1, tibialis anterior L5, vastus medialis L2-4, and vastus lateralis L2-4. 
Therefore, the records do support that the CPT code 95886 was actually rendered in this case. 
 
In terms of CPT 95909, the technical report did support that there were nerve conduction studies performed. 
Nerve conduction tests results note stimulation of the pedicle screws utilizing a monopolar ball tip probe 
revealed motor responses at thresholds consistent with intact pedicles that were satisfactory to the surgeon. The 
pedicle levels were L4, L5, and S1. Therefore, the records do support that the CPT 95909 code was actually 
rendered in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
95886 and 95909.  
 
We also decided that the Plan does not have to pay for 95822 and 95999. 
 
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 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 CPT 95822 and CPT 95999.  
 
Our reviewer says that in terms of CPT 95822, the specific code used here is noted to be for a recording in a 
coma or sleep study. These situations do not apply to the enrollee. Therefore, the records do not support that 
CPT 95822 was actually rendered in this case. 
 
In terms of CPT 95999, detailed documentation is not evident regarding what procedure is being billed using 
CPT 95999. The records do not make it clear if this is being used to bill for the 'train of four' monitoring. The 
code cannot be supported. Therefore, the records do not support CPT 95999. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95822 and 95999 have not been met. Therefore, we decided that the Plan does 
not have to pay for 95822 and 95999. 
 
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.