Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95955, 95861, and 95868. We decided that the Plan does not have to 
pay for 95908, 95927, and 95937.  
 
You asked the Plan to pay for procedure codes 95861, 95868, 95908, 95927, 95937, and 95955 rendered on 
March 15, 2021.. 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 95955, 95861, and 95868.  
 
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 
the denied codes is: 
 
CPT 95861: 
 
Needle electromyography; 2 extremities with or without related paraspinal areas 
 
CPT 95868: 
 
Needle electromyography; cranial nerve supplied muscles, bilateral 
 
CPT 95955: 
 
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 these codes. Our reviewer says that CPT 95955 was 
supported in the records. Per the physician's report, it can be said that the professional component of this 
service was rendered. The intra-operative neuromonitoring report indicated that an electroencephalogram 
(EEG) had been performed, and an analysis was provided. 
 
Additionally, CPT 95861 was supported in the medical records. The records show that the professional 
component of this service was rendered. The report indicates that free running electromyography (EMG) was 
performed in the upper extremities. 
 
Finally, CPT 95868, the physician's report shows that the professional component of this service was rendered. 
The report indicates that free running EMG was performed in the trapezius muscles bilaterally.  
 
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 
95955, 95861, and 95868.  
 
We also decided that the Plan does not have to pay for 95908, 95927, and 95937. 
 
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 the denied codes is: 
 
CPT 95908:  
Nerve conduction studies; 3-4 studies 
 
CPT 95927: 
 
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 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
In this case, we have confirmed that code 95908 is a column II code to column I code 95861 with a modifier 
indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare billing 
criteria have not been met for CPT 95908. 
 
Additionally, 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 95927 and CPT 95937. Our reviewer 
says that the records do not support CPT 95927. The services provided would have been more appropriately 
coded under CPT 95938. Additionally, the records do not support the use of CPT 95937, as the records indicate 
that train of four testing was performed. This is distinct from normal neuromuscular junction (NMJ) testing for 
a neuromuscular disorder, which would otherwise be the more appropriate use of this 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 95908, 95927, and 95937 have not been met. Therefore, we decided that the 
Plan does not have to pay for 95908, 95927, and 95937. 
 
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.