Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services on March 27, 2022. We decided that the Plan does not 
have to pay for the services on March 28, 2022.  
 
You asked the Plan to pay for initial hospital care (procedure code 99222) rendered from March 27, 2022 to 
March 28, 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 the services on March 27, 2022.  
 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 99222 is "Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision 
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 
minutes are spent at the bedside and on the patient's hospital floor or unit." 
 
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 99222 on March 27, 2022. Our reviewer says 
that the documentation indicates there was an initial evaluation on 3/27/2022 that contained a comprehensive 
history, physical exam and medical decision making of moderate complexity supporting the CPT code 99222. 
 
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 
the services on March 27, 2022.  
 
We also decided that the Plan does not have to pay for the services on March 28, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
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 99222 on March 28, 2022. Our reviewer says 
that there is no documentation from March 28, 2022 to support CPT 99222. 
 
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 on March 28, 2022 have not been met. Therefore, we decided that 
the Plan does not have to pay for the services on March 28, 2022. 
 
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.