Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services billed with code 95955. We decided that the Plan does not 
have to pay for the services billed with codes 95908 and 95937.  
 
You asked the Plan to pay for the neuromonitoring services provided on March 18, 2021, billed with codes 
95955, 95908, and 95937. You say that the monitoring was necessary and billed correctly. The Plan says that 
these codes are not supported. 
 
We decided that the Plan has to pay for the services billed with code 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 CPT Manual definition of code 95955 is electroencephalogram (EEG) during nonintracranial surgery (eg, 
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 billed with code 95955. Our reviewer says that 
this code is supported by the records. Our reviewer found that the medical records support the use of procedure 
code 95955 as the EEG was performed on the enrollee during a laminectomy. This code is to be used on any 
surgery outside of brain surgery. 
 
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services billed with code 95955 have been met. Therefore, we decided that 
the Plan has to pay for the services billed with code 95955.  
 
We also decided that the Plan does not have to pay for the services billed with codes 95908 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 CPT Manual definition of code 95937 is neuromuscular junction testing (repetitive stimulation, paired 
stimuli), each nerve, any 1 method. 
 
CPT code 95908 is a Column II code in relation to Column I code 95861. 95908 was not billed with a required 
modifier to bypass the edit.  
 
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 billed with codes 95908 and 95937. Our 
reviewer says that these two codes are not supported. Our reviewer found no modifier was used with 95908 
meaning it is not billed correctly. As for code 95937, records do not support this code as the documentation 
describes that of another procedure that was paid and processed properly.  
We looked at this coders review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services billed with codes 95908 and 95937 have not been met. Therefore, 
we decided that the Plan does not have to pay for the services billed with codes 95908 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.