Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95940. We decided that the Plan does not have to pay for 95955, 
95870, 95938.  
 
You asked the Plan to pay for neurology services (procedure codes 95955, 95870, 95938, 95940) provided to 
the enrollee on April 13, 2022.. You say that this should be paid for. The Plan says that the denied codes 
remain not supported. 
 
We decided that the Plan has to pay for 95940.  
 
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 coding 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 95940. Our reviewer says that this code is an 
add-on code. However, in this case the primary code CPT 95937 was approved reimbursement. Therefore, this 
procedure was reported with an approved procedure code.  
 
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 
95940. 
 
In this case, the definition of the denied codes is: 
 
CPT 95955: 
 
Electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery) 
 
CPT 95870: 
 
Needle electromyography; limited study of muscles in 1 extremity or non-limb (axial) muscles (unilateral or 
bilateral), other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters 
 
CPT 95938: 
 
Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, 
recording from the central nervous system; in upper and lower limbs 
 
CPT 95940: 
 
Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring 
personal attendance, each 15 minutes (List separately in addition to code for primary procedure)  
 
We also decided that the Plan does not have to pay for 95955, 95870, 95938. 
 
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 coding 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 the rest of the codes.  
 Our reviewer says that in terms of CPT 95955, the procedure report does not include documentation of 
electroencephalogram (EEG) during nonintracranial surgery (eg, carotid surgery). Additional EEG testing 
would be inclusive of the primary neuromonitoring procedure. In this case, a "special EEG tests" per CPT code 
cannot be verified. 
 
In terms of CPT 95870 and 95938, these procedures were reported with modifier TC, and place of service 
(POS) 22. In this case, if equipment is owned by provider a professional component would also be appended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95955, 95870, 95938 have not been met. Therefore, we decided that the Plan 
does not have to pay for 95955, 95870, 95938. 
 
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.