Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95886, 95908 and 95999. We decided that the Plan does not have to 
pay for 95822.  
 
You asked the Plan to pay for neurology services provided to the enrollee on March 23, 2022.. You say that 
this should be paid for. The Plan says that the records do not support the services billed. 
 
The definition of the denied codes is: 
 
CPT 95822: 
 
Electroencephalogram (EEG); recording in coma or sleep only 
 
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 95999: 
 
Unlisted neurological or neuromuscular diagnostic procedure 
 
We decided that the Plan has to pay for 95886, 95908 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 CPT 95886, 95999 and CPT 95908. Our reviewer 
says that the records do support that CPT 95886, 95999, and 95908 was rendered in this case. The technical 
report indicated that the lower EMG recording sites included abductor hallucis S1-2, gastrocnemius L5-S1, 
tibialis anterior L4-S1, vastus lateralis L2-4, and vastus medialis L2-4. This included 5 muscles, supporting 
CPT 95886. Additionally, the nerve conduction study was performed at the bilateral L4 and L5 indicating 4 
levels, supporting CPT 95908. Additionally, there was train of four utilized during the procedure, represented 
by CPT 95999.  
 
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, 95908 and 95999.  
 
We also decided that the Plan does not have to pay for 95822. 
 
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 95822. Our reviewer says that the records do 
not support that CPT 95822 was rendered in this case. The technical report indicated that an EEG was 
performed during the procedure on 3/23/22. However, the code listed (CPT 95822: Electroencephalogram 
(EEG); recording in coma or sleep only) would not be the correct/best code to use for an electroencephalogram 
during surgery. There are more accurate CPT codes to represent an electroencephalogram (EEG) that is 
performed during intraoperative monitoring, including CPT 95812- Electroencephalogram (EEG) extended 
monitoring; 41-60 minutes or 95813- Electroencephalogram (EEG) extended monitoring; greater than 1 hour. 
 
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 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95822. 
 
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.