Appeal type: Inpatient Hospital
Decision: Unfavorable

Maximus Federal Services will then send your request form and the case file used to decide your appeal to the OMHA office in your jurisdiction for review. Once this is done, any further communications regarding your appeal will come directly from the OMHA office.How we made our decision  1. We read all the papers in the file.2. We checked Medicare rules.3. We checked the contract with the Plan. 4. If required, we sent the file to a Maximus Federal Services physician reviewer.To make our decision we read all the papers in the file very carefully. We used the Medicare rules. We looked to see if the Plancorrectly followed Medicare rules and regulations.Medicare rules say that the Plan must give the member a subscriber agreement. It is a contract between the Plan and the member. It is usually called the "Evidence of Coverage"(EOC)or "Member Agreement." We read this contract carefully to see what the Planis supposed to cover.Medicare rulesThe rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that providers must report services correctly. Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in the Centers for Medicare and Medicaid Services,Medicare National Correct Coding Initiative Policy Manual for Medicare Services, Chapter I(A).If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.Explanation of decisionWe decided that the Plandoes not haveto pay forhospital discharge day management services (CPT 99239) provided to the enrollee on July 20, 2020.You asked the Planto pay forthe services. You say that this should be paid for.The Plandenied your request. The Plansaysthe records do not support the services billed.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 99239 is "hospital discharge day management of more than 30 minutes."We asked our physician reviewer to carefully review the case file and applythe relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the documentation submitted was reviewed, and it does not document the time to support billing CPT 99239. 31 minutes or more are required for this code. The only time documented is 16 minutes of dictation time. Therefore, this CPT code cannot be confirmed. e 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 not been met.Therefore, we decided that the Plandoes not haveto pay forhospital discharge day management services (CPT 99239) provided to the enrollee on July 20, 2020