Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886 and 95955. We decided that the Plan does not have to pay for 
95908.  
 
You asked the Plan to pay for needle electromyography/nerve conduction studies/electroencephalogram (EEG) 
during nonintracranial surgery provided to the enrollee on February 2, 2022.. You say that this should be paid 
for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 95886 and 95955.  
 
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 CPT 95886 is "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)." Additionally, the definition of CPT 95955 is "Electroencephalogram (EEG) during nonintracranial 
surgery (eg, carotid surgery)." 
 
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 95886 and CPT 95955. Our physician 
reviewer found that the records do support that these codes were rendered in this case. The technical report 
indicated that lower electromyography had recording sites of abductor hallucis, gastrocnemius, iliopsoas, 
tibialis anterior, and vastus lateralis. Also, the technical report corroborated that an electroencephalogram was 
performed during this procedure. 
 
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 
95886 and 95955.  
 
We also decided that the Plan does not have to pay for 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. In this case, the CPT Code Manual definition of 
CPT 95908 is "Nerve conduction studies; 3-4 studies." 
 
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 95955 Our reviewer says that the technical 
report did not corroborate that any nerve conduction studies were rendered in this case. The enrollee is noted to 
have had upper and lower somatosensory evoked potentials (SSEPs), upper and lower motor evoked potentials 
(MEPs), electromyography, pedicle testing, and electroencephalogram. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95908 have not been met. Therefore, we decided that the Plan does not have to 
pay for 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.