Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography represented by code 95885, nerve conduction studies represented by code 95908, short-latency somatosensory evoked potential study represented by code 95927, and electroencephalogram represented by code 95955.
You asked the Plan to pay for codes 95885, 95908, 95927, and 95955. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the medical records do not support the services 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 code 95885 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). The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95927 is 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. The CPT Code Manual definition of code 95955 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 codes 95885, 95908, 95927, and 95955. Our reviewer says that the criteria for coverage of the codes in dispute have not been met. Our reviewer found the medical records provided do not document that a limited needle electromyography with nerve conduction was performed on January 29, 2021. The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, therefore this service cannot be verified. The medical records provided do not document that a nerve conduction study of 3-4 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. The medical records submitted does not include sufficient information to validate that 95927 was performed as an independent procedure. Therefore, this service cannot be verified and 95927 is inclusive to the SSEP of the ulnar nerve. The medical records provided do not include sufficient documentation to validate that an Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) was performed on January 29, 2021; therefore, this service cannot be verified.
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 95885, 95908, 95927, and 95955 have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography represented by code 95885, nerve conduction studies represented by code 95908, short-latency somatosensory evoked potential study represented by code 95927, and electroencephalogram represented by code 95955.