Does 95926 require prior authorization?

No, 95926 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 95926?

Medicare facility rate: $135.94. Non-facility rate: $135.94. Work RVU: 0.53.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.53

Facility

$135.94

Non-Facility

$135.94

Claims must include documentation supporting medical necessity per LCD L34433, such as relevant clinical history, indication for testing, the somatosensory test report, and the interpreting clinician's signature.
Follow any payer-specific billing requirements, coding modifiers, and prior authorization processes specified by the LCD or local payers when submitting claims for somatosensory testing.
Refer to LCD L34975 for the detailed reasonable and necessary clinical criteria and documentation required to support coverage of NEPs.
Use CPT codes 95925, 95926, 95927, 95928, 95929, 95938, and 95939 for Somatosensory Evoked Potentials/Responses (SEPs/SERs).

Coverage indications for somatosensory testing follow the Local Coverage Determination L34433; this article provides billing and coding guidance only.
Neurophysiology Evoked Potentials (NEPs) — including Somatosensory Evoked Potentials (SEPs), Brainstem Auditory Evoked Potentials (BAEPs/BAERs), and Visual Evoked Potentials (VEPs/VERs) — are covered when determined to be reasonable and necessary in accordance with LCD L34975.
Somatosensory testing is covered when it is medically necessary, ordered by a referring/ordering physician, and the medical record documents relevant history, physical exam, and pertinent diagnostic tests supporting the need for the test.
Diagnostic somatosensory tests should be performed when test results are expected to influence or contribute to the patient’s course of treatment.
For diagnostic tests, report the test result if known; if result is not available, report the symptoms that prompted the test on the claim.
Somatosensory evoked potential (SEP) testing should be billed using CPT codes 95925, 95926, 95927, or 95938 when an SEP study (not QST) is performed.

L34624 — Somatosensory Testing

J05

A57597 — Billing and Coding: Somatosensory Testing

J05

L33693 — Peripheral Venous Ultrasound

J09

A56773 — Billing and Coding: Neurophysiology Evoked Potentials (NEPs)

J12

L35007 — Vestibular and Audiologic Function Studies

Ask Verity about documentation requirements, denial risks, or coverage in your state.