Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886 and 95910. We decided that the Plan does not have to pay for 
95822 and 95999.  
 
You asked the Plan to pay for procedure codes 95822, 95886, 95910, and 95999 provided to the enrollee on 
May 3, 2022.. You say that this should be paid for. The Plan says that the denied codes are not supported in the 
medical records submitted. 
 
We decided that the Plan has to pay for 95886 and 95910.  
 
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 95886 and 95910. Our physician reviewer found 
that in terms of CPT 95886, the technical report cites lower electromyography (EMG) recording sites were: 
abductor hallucis, gastrocnemius, tibialis anterior, vastus lateralis, and vastus medialis. This supports 5 muscles 
were being tested/monitored. Therefore, the records do support that CPT 95886 was rendered in this case. 
 
In terms of CPT 95910, the technical report cites the nerve conduction test was performed at the bilateral L3, 
L4, L5, and S1. Since the test was bilateral, there are 8 sites studied/monitored. Therefore, the records do 
support that CPT 95910: nerve conduction studies, 7-8 studies were rendered in this case. 
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 95910.  
 
We also decided that the Plan does not have to pay for 95822 and 95999. 
 
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 95822 and 95999. Our physician reviewer found 
that in terms of CPT 95822, the technical report does indicate that an electroencephalogram was performed. 
However, this code is not supported as the enrollee was not in a coma or sleep. There are typically more 
appropriate codes to use in this clinical scenario. (e.g., 95812 and 95813). 
 
In terms of CPT 95999, the technical report noted that a train of four was utilized to assess the presence of 
neuromuscular blockade. The CPT code 95999 was billed for this procedure. However, train-of-four 
monitoring is considered integral to intraoperative neuromonitoring and/or administration of anesthesia and, 
therefore, is not separately reportable.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95822 and 95999 have not been met. Therefore, we decided that the Plan does 
not have to pay for 95822 and 95999. 
 
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.