Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95937 and 95957. We decided that the Plan does not have to pay for 
95886 and 95908.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the denied 
codes remain not supported. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
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 95908: 
 
Nerve conduction studies; 3-4 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
CPT 95957: 
 
Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) 
 
We decided that the Plan has to pay for 95937 and 95957.  
 
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 95937 and CPT 95957. Our reviewer says that 
the records do support that these codes were actually rendered in this case. The procedure report documents 
that neuromuscular junction monitoring (train of four), electrical stimulation was applied to a peripheral nerve 
and recorded from the corresponding muscles in order to assess the level of neuromuscular blockade was 
performed as well as an EEG (electroencephalogram) monitoring, recording electrodes consisted of subdermal 
needle electrodes applied according to the International 10-20 System. 2-4 EEG channels were recorded in a 
bipolar montage in order to correlate general level of anesthesia with changes observed in evoked potential 
data. 
 
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 
95937 and 95957.  
 
We also decided that the Plan does not have to pay for 95886 and 95908. 
 
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 95908. Our reviewer says that the 
enrollee was being treated for spondylosis of the lumbosacral region; spinal stenosis of the lumbosacral region; 
and low back pain. She underwent a posterior spinal fusion at S1 to S2 and kyphoplasty of S1 on 
7/19/21. However, detailed documentation is not evident regarding that during the procedure on 7/19/21 that 
nerve conduction studies were performed along with the electromyography. There is no documentation of 
nerve conduction studies having been performed. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95886 and 95908 have not been met. Therefore, we decided that the Plan does 
not have to pay for 95886 and 95908. 
 
 
 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.