Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95937, 95908, and 95927 provided September 3, 2020.

You asked the Plan to pay for the medical services. You say that the medical records submitted support the documentation as billed. The Plan denied your request. The Plan says the medical record does not support the codes as 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 the billed codes is listed below:

95955 - 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) 
95885 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
95937 - Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
95908 - Nerve conduction studies; 3-4 studies
95927 - 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 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 medical services. Our reviewer says that the medical records do not support the codes as billed. Our reviewer found that for CPT 95955, the technical report documents "real time" monitoring. This procedure would be included in the primary procedure intraoperative neuromonitoring code. For CPT 9588, this code would not be covered, as all requirements in the description of the code were not performed. In this case technical report does not include documentation of nerve conduction studies. For CPT 95937, the technical report does not document neuromuscular junction testing, and therefore this procedure cannot be confirmed as performed. For CPT 95908, the technical report documents pedicle screw stimulation. This procedure is inappropriate to report for nerve conduction studies which includes electrodes placed directly over the nerves, to include measurement of amplitude, latency and conduction velocity. Therefore, this procedure cannot be confirmed as performed. Finally for CPT 95927, the technical report does not document trunk or head stimulation. Per documentation "SSEP were performed to monitor the sensory system by stimulation nerves in the upper and lower extremities. Baseline responses were recorded prior to the start of the procedure and subsequent responses were compared to baseline." Documentation does not support electrodes on the scalp, and therefore cannot be confirmed as performed. 

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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95955, 95885, 95937, 95908, and 95927 provided September 3, 2020.