Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95955. We decided that the Plan does not have to pay for 95885, 
95908, 95927, and 95937.  
 
You asked the Plan to pay for procedure codes 95885, 95908, 95927, 95937, 95955 rendered on March 22, 
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.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 95955. Our reviewer says that per the 
physician's report, it can be said that the professional component of this service was rendered. The report 
indicates that electroencephalogram (EEG) was performed during the 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 
95955.  
 
We also decided that the Plan does not have to pay for 95885, 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. The definition of the upheld codes is: 
 
CPT 95885: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary 
procedure) 
 
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 95885 and 95908 are column II codes to column I code 95861 with a 
modifier indicator of 0. The column II codes are therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
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 95937. Our reviewer says 
that while somatosensory evoked potentials (SSEPs) were rendered during the course of the procedure, the 
more appropriate code to be utilized would have been CPT 95938. Therefore, CPT 95927 was not supported in 
this case. In terms of CPT 95937, the services provided reflect train of four (ToF) testing. This specific service 
is otherwise considered to be part of the electromyography (EMG) codes billed for. CPT code 95937 is not 
otherwise indicated for use in TOF testing, as this code is primarily reserved for testing of the neuromuscular 
junction for evaluation of suspected neuromuscular disease. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95885, 95908, 95927, and 95937 have not been met. Therefore, we decided that 
the Plan does not have to pay for 95885, 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.