Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT code(s): 95885-26 x2, 95909-26 and 
95955-26) provided on April 11, 2022. 
 
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. 
 
In this case, the CPT Code Manual definition of code 95885-26 x2 is 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), 95909-26 is nerve conduction 
studies; 5-6 studies and 95955-26 is electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery)  
 
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 95885-26 x2 was 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. After review of the technical 
report, the requested service code was not substantiated by the clinical documentation in the medical records. 
Procedure code 95909-26 is not supported by the medical records submitted. The technical report did not 
include documentation of a nerve conduction studies; for 5-6 studies; therefore, this code cannot be verified. 
After review of the technical report, the requested service code was not substantiated by the clinical 
documentation in the medical records submitted for review. To cite the technical report; "Electrical Stimulation 
of the pedicle screws was done by triggered EMG performed by probe stimulation of each stimulated screw. 
The surgeon acknowledged and accepted all stimulated screws final threshold stimulation values and the final 
position for all screws placed by the surgeon. Procedure code 95955-26 is not supported by the medical records 
submitted. The technical report did not include documentation of an electroencephalogram (EEG) during 
nonintracranial surgery (carotid surgery); therefore, this code cannot be verified. After careful review of the 
technical report, the requested service code was not substantiated by the clinical documentation in the medical 
records submitted for review. The review has determined that the documentation did not support procedure 
code 95885-26 x2, 95909-26, 95955-26. 
 
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 the services (CPT code(s): 95885-26 x2, 95909-26 and 95955-26) provided on April 11, 2022.