Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95907, 95927 and 95955. We decided that the Plan does not have to 
pay for 95885.  
 
You asked the Plan to pay for procedure codes 95885, 95907, 95927, and 95955 rendered on August 18, 2021.. 
You say that this should be paid for. The Plan says that the procedure codes are not supported by the medical 
records submitted.  
We decided that the Plan has to pay for 95907, 95927 and 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 the denied codes is: 
 
CPT 95907: 
 
Nerve conduction studies; 1-2 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 95955: 
 
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 95907, CPT 95927, and CPT 95955. In terms 
of CPT 95907, that the technical report cites that nerve conduction study was performed with recording sites of 
Erb's point and popliteal fossa. Therefore, the records do support that CPT 95907 were rendered in this case. 
 
In terms of CPT 95927, the technical report cites upper SSEP (somatosensory evoked potential) was performed 
with stimulation sites of the ulnar nerve. The lower SSEP (somatosensory evoked potential) was performed 
with stimulation sites of posterior tibial. Therefore, the records do support that CPT 95927 was rendered in this 
case. 
 
In terms of CPT 95955, the technical report cites an EEG (electroencephalogram) was also performed. The 
correct code has been utilized as this is not an intracranial surgery. Therefore, the records do support that CPT 
95955 was rendered in this case. 
 
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 
95907, 95927 and 95955.  
 
We also decided that the Plan does not have to pay for 95885. 
 
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 95885 is "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)." 
 
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 95885. Our reviewer says that the services at 
issue in this case were not supported by the medical records. The technical report cites lower need 
electromyography was performed with recording sites of abductor hallucis, gastroc, peroneus longus, tibialis 
anterior, and vastus medialis. Axial electromyography was performed with recording site of rectus femoris. The 
documentation does not support any electromyography having been performed of the upper extremities. 
Therefore, the records do not support that CPT 95885 was rendered in this case. 
 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 have not been met. Therefore, we decided that the Plan does not have to 
pay for 95885. 
 
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.