Appeal type: Testing
Decision: Partially Favorable

 
We decided that the Plan has to pay for 95955. We decided that the Plan does not have to pay for 95886, 
95909, and 95937.  

You asked the Plan to pay for procedure codes 95886, 95909, 95937, and 95955 rendered on February 22, 
2022.. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 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. 
 
In this case, the CPT Code Manual definition of CPT 95955 is "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 95955. Our reviewer says that the technical 
report cites than EEG was performed. This was a non-intracranial procedure. Therefore, the records support 
this code. 
 
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 95955.  
 
We also decided that the Plan does not have to pay for 95886, 95909, 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 definition of the upheld codes is: 
 
CPT 95886: 
 
Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three 
or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) 
 
CPT 95909: 
 
Nerve conduction studies; 5-6 studies 
 
CPT 95937: 
 
Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method 
 
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 these codes. Our reviewer says that in terms of CPT 
95886, the technical report cites that an EMG (electromyography) was performed. However, it was on the 
lower extremities and not on each extremity. Therefore, this code was not supported.  
 
In terms of CPT 95909, the technical report cites that upper and lower somatosensory evoked potentials (SSEP) 
and motor-evoked potentials (MEP), EMG, pedicle testing, EEG, and train of four testing were performed. 
Therefore, the records do not support this code. 
 
In terms of CPT 95937, the technical report cites that pedicle testing was performed at the right L1, bilateral 
L2, bilateral L3, bilateral L4, and bilateral S1. However, the L1 was only performed on the right side and 
would not be paired stimuli. Therefore, the records do not support this code. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95886, 95909, and 95937 have not been met. Therefore, we decided that the 
Plan does not have to pay for 95886, 95909, 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.