Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (95861, 95908, 95927, 95937 
and 95955) billed for date of service March 16, 2021.  
 
You asked the Plan to pay for the services. You say that  these services were necessary and were reported 
appropriately.  The Plan denied your request. The Plan says these services are not supported in the medical 
record.  
 
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 code 95908 is nerve conduction studies; 3-4 studies. The 
definition of code 95927 is short-latency somatosensory evoked potential study about the stimulation of any/all 
peripheral nerves or skin sites by recording from the central nervous system; in the trunk or head. The 
definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, by any 1 method. The definition of code 95955 is electroencephalogram (EEG) during nonintracranial 
surgery (carotid surgery). 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer found for code 95861, the 
documentation submitted was reviewed and does not meet criteria. The procedure report does not describe 
needle electromyography for test of 2 extremities with or without related paraspinal areas. Per NCCI Policy, 
"Needle electromyography (EMG) records the electrical properties of muscle using an oscilloscope. 
Recordings, which may be amplified and heard through a loudspeaker, are made during needle insertion, with 
the muscle at rest, and during contraction. These codes are reported when there are no nerve conduction studies 
performed in conjunction with these procedures during the same day. This procedure was not documented in 
the report submitted. 
 
For code 95908, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not include documentation of nerve conduction studies. The procedure report describes pedicle screw 
stimulation, which would not be reported with nerve conduction procedure codes. Therefore, this procedure 
code cannot be verified. As of note, this procedure has a coding conflict with code 95861, as this procedure is 
reported when no nerve conduction studies are performed. 
 
For code 95927, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not describe SSEP stimulation of any/all peripheral nerves or skin sites by recording from the CNS; in 
trunk or head. For code 95927, the provider performs a shortlatency somatosensory evoked potential study by 
stimulating the peripheral nerves or skin sites in the trunk or head. The provider records the resulting evoked 
potential study from the central nervous system. Our coder reviewer was unable to cite report, as this procedure 
was not found in documentation.  
 
For code 95937, the documentation submitted was reviewed and does not meet criteria. The procedure report 
describes T04 testing, "TOF TEST PRODUCED 1/4 TWITCHES DURING PRE-INCISION. SURGEON 
REQUESTED PATIENT TO BE PARALYZED DURING EXPOSURE. AFTER EXPOSURE, TOF 4/4 AND 
REMAINED 4/4 WHERE EMG MONITORING WAS REQUIRED. AT CLOSING TO4 WAS 4/4". T04 
would not be reported with neuromuscular junction testing. T04 does not have an assigned procedure code, as 
this procedure is included in the primary neuromonitoring procedure codes. 
 
For code 95955, the documentation submitted was reviewed and does not meet criteria. The procedure report 
describes neuromonitoring service provided for TLIF L5 - S1. In this case, this procedure would not be 
appropriate. In this procedure, the provider uses electroencephalographic monitoring of a patient during 
nonintracranial surgery like cardiac surgery or carotid stenting. Therefore, this procedure code cannot be 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for the nerve conduction studies (95861, 95908, 95927, 95937 and 95955) billed for date of service 
March 16, 2021.