Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nerve conduction studies; 1-2 studies (CPT code 95907 26, 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) (95886 26), needle electromyography; larynx (95865 26 59), unlisted neurological or neuromuscular diagnostic procedure (95999 59) and electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) (95955 26 59) provided to the enrollee on August 17, 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 CPT code 95907 26, nerve conduction studies; 1-2 studies billed to the health plan for services on August 17, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that a nerve conduction studies; 1-2 studies was performed on August 17, 2021, as pedicle screws or direct root stimulations are not baseline nerve conduction studies, therefore, this service cannot be verified. Medicare rules state, "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met." "Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed." 

CPT code 95886 26 -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) billed to the health plan for services provided on August 17, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation of a 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) being performed on August 17, 2021, as the medical records do not include documentation that a nerve conduction study was performed. Pedicle screws or direct root stimulations are not baseline nerve conduction studies. A nerve conduction study is required to meet CPT definition of 95886. Therefore, this service cannot be verified. Medicare rules state, "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met." "Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed." 

CPT code 95955 26 59 - Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) billed to the health plan on August 17, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include sufficient documentation to validate that an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) was performed on August 17, 2021, as a real time EEG is not covered under CPT 95955; therefore, this service cannot be verified.

Medicare rules state, For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met." Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been performed. 

CPT code 95999 59 - unlisted neurological or neuromuscular diagnostic procedure billed to the health plan on August 17, 2021, does not meet criteria for billing or reimbursement consideration. The medical records provided does not include documentation of an unlisted neurological or neuromuscular diagnostic procedure on August 17, 2021, therefore, this procedure cannot be verified. The medical records indicate train of four testing was done, which is considered inclusive when performed during intraoperative neurophysiological monitoring and is not eligible for additional reimbursement. Also, 95999 in an unlisted procedure and no lay description available. In order to bill 95999, the operative note must include specific documentation that describes or indicates the procedure that is being billed under code 95999. There was no such description documented in the operative note. Medicare rules state, "For Medicare to consider coverage and payment for an item or service, the information submitted by the supplier or provider must corroborate the services so we can confirm Medicare coverage has been met." "Physicians must report services correctly. There are certain types of improper coding that physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all services described by that code have been 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 services have not been met. Therefore, we decided that the Plan does not have to pay for the nerve conduction studies; 1-2 studies (CPT code 95907 26, 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) (95886 26), needle electromyography; larynx (95865 26 59), unlisted neurological or neuromuscular diagnostic procedure (95999 59) and electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) (95955 26 59) provided to the enrollee on August 17, 2021.