Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for code 95938-26. We decided that the Plan does not have to pay for code 
95822-26.   

You asked the Plan to pay for imaging services provided on December 22, 2022, billed with codes 95938-26, 
95822-26, and 95939-26. You say that the claim is billed correctly and should be paid. The Plan says that 
documentation does not support code 95822-26. The Plan also says code 95938-26 is bundled and is not 
separately payable. 
 
We decided that the Plan has to pay for code 95938-26.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 to pay for procedure code 95938-26. Our reviewer says 
that the billed codes partially meet criteria. Our physician reviewer found that procedure code 95822-26 is not 
supported. The documentation does not contain evidence that an electroencephalogram was performed during 
sleep or a coma. The record states that an electroencephalogram was performed as part of intraoperative 
neuromonitoring. This is included in the code(s) for intraoperative neuromonitoring and is not separately 
reportable. Procedure code 95938-26 is supported. The record states that upper and lower SSEPs were 
performed with latency and amplitude.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 95938-26 have been met. Therefore, we decided that the Plan 
has to pay for code 95938-26.  
 
We also decided that the Plan does not have to pay for code 95822-26. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
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 to pay for 95822-26. Our reviewer says that the billed 
codes partially meet criteria. Our physician reviewer found that procedure code 95822-26 is not supported. The 
documentation does not contain evidence that an electroencephalogram was performed during sleep or a coma. 
The record states that an electroencephalogram was performed as part of intraoperative neuromonitoring. This 
is included in the code(s) for intraoperative neuromonitoring and is not separately reportable. Procedure code 
95938-26 is supported. The record states that upper and lower SSEPs were performed with latency and 
amplitude.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 95822-26 have not been met. Therefore, we decided that the Plan does not have 
to pay for code 95822-26. 
 
 
 
 
 
 
 
 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.