Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 95886-26-29, 95822-26-XU, 95937-26, 95927-26-XS, 
and 95907-26 provided on December 29, 2021. 
 
You asked the Plan to pay for codes 95886-26-29, 95822-26-XU, 95937-26, 95927-26-XS, and 95907-26. You 
say that you have submitted medical records to support payment of these codes. The Plan denied your request. 
The Plan says these codes 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 95886 is complete needle electromyography, per each 
extremity with related paraspinal areas when performed, done with nerve conduction, amplitude and 
latency/velocity study; for five or more muscles studied, innervated by three or more nerves or four or more 
spinal levels (listed separately in addition to code for primary procedure). The definition of code 95822 is  electroencephalogram (EEG), recording of patient in coma or sleep only. The definition of code 95937 is 
neuromuscular junction testing (repetitive stimulation, paired stimuli) for each nerve, by any 1 method. 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 95907 is nerve conduction studies, for 1-2 studies. 
 
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 codes 95886-26-29, 95822-26-XU, 95937-26, 95927-26-XS, 
and 95907-26. Our reviewer says that codes 95886-26-29, 95822-26-XU, 95937-26, 95927-26-XS, and 95907-
26 are not supported in the medical record. Our reviewer found for code 95886, the procedure report does not 
include documentation of nerve conduction studies, and therefore this procedure cannot be verified. For code 
95822, this procedure would not be reported when performing neuromonitoring for a surgical 
procedure.  Additional electroencephalogram (EEG) services are included in the primary neuromonitoring 
procedure codes. For code 95937, the procedure report does not include documentation of neuromuscular 
junction testing. The procedure report describes T04 which would be included in the primary neuromonitoring 
procedure. There is no assigned procedure code for the T04 procedure. For code 95927, the procedure report 
includes insufficient documentation to describe 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 For code 95907, pedical screw stimulation would not be 
reported as pedicle screw stimulation, as nerve conduction measure amplitude and latency/velocity study.  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 95886-26-29, 95822-26-XU, 95937-26, 95927-26-XS, and 95907-26 
have not been met. Therefore, we decided that the Plan does not have to pay for codes 95886-26-29, 95822-26-
XU, 95937-26, 95927-26-XS, and 95907-26 provided on December 29, 2021.