Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services (95868, 95908, 95927, 95937 and 
95955) provided on March 30, 2021. 
 
You asked the Plan to pay for the medical services. You say that this should be paid for.  The Plan denied your 
request. The Plan says the records do not support the services billed.  
 
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 95868 is needle electromyography; cranial nerve supplied 
muscles, bilateral. The definition of code 95908 is nerve conduction studies; 3-4 studies. The definition of code 95927 is 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. The definition of code 95937 is 
neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method. The 
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 medical services. Our reviewer found for code 95868, the 
documentation submitted was reviewed and does not meet criteria. The procedure report does not include 
documentation of electromyography; cranial nerve supplied muscles, bilateral. Per National Correct Coding 
Initiative (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 specific to the 12 nerves that emerge 
from or enter the cranium. These codes are reported when there are no nerve conduction studies performed in 
conjunction with these procedures during the same day. Report 95867 for unilateral studies and 95868 for 
bilateral studies. This procedure was not found in documentation submitted. 
 
For code 95908, the documentation submitted was reviewed and does not meet criteria. Although nerve 
conduction studies are documented in procedure report, a procedure-to-procedure (PTP) edit exists with CPT 
95861, with indicator 0. In this case, this procedure would not be separately reported, as modifier indicator of 
0 indicates that an edit can never be bypassed even if a modifier is used. 
 
For code 95927, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not include documentation of somatosensory evoked potentials (SSEP) of peripheral nerves or skin sites, 
recording from the central nervous system (CNS), in trunk or head. In this procedure, the provider performs a 
short-latency 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. This 
description was not found in procedure report, and therefore, cannot be verified. 
 
For code 95937, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not include documentation of neuromuscular junction testing. Our coder was unable to cite report, as this 
procedure was not found in documentation submitted. 
 
For code 95955, the documentation submitted was reviewed and does not meet criteria. The procedure report 
does not include documentation of electroencephalogram (EEG)during nonintracranial surgery. The procedure 
report documents, "ACDF C5-C7" was performed, and in this case, there is a more appropriate code to report 
for service provided. In this procedure, the provider uses electroencephalographic monitoring of a patient 
during nonintracranial surgery like cardiac surgery or carotid stenting. This procedure is not included in 
documentation submitted.  
 
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 medical services have not been met. Therefore, we decided that the Plan 
does not have to pay for the medical services (95868, 95908, 95927, 95937 and 95955) provided on March 30, 
2021.