Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by codes 49440, 49441, and 99152. We decided 
that the Plan does not have to pay for the services described by code 99153.  
 
You asked the Plan to pay for the surgical services provided on October 21, 2021. You say that this should be 
paid in full. The Plan says that the denial has been upheld for code 99153 as this is not payable in a facility 
setting. The remaining codes are being handled as a reopening of the claim denial, meaning Maximus should 
no 
 
We decided that the Plan has to pay for the services described by codes 49440, 49441, and 99152.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make a reconsideration determination for the codes 
at issue. The Plan indicated that the organization determination was reopened; however, according to Section 
80.2 of the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance, 
The reopening process is separate and distinct from the appeals process. When a party has filed a valid 
request for a level 1 appeal, level 2 appeal, ALJ or attorney adjudicator decision, or Council review, no 
adjudicator has jurisdiction to reopen a case that is under appeal until all appeal rights for that case are 
exhausted or a subsequent request by the appellant to withdraw the appeal has been granted. 
 
Because your request for these codes was filed as an appeal, the Plan does not have the jurisdiction to reopen 
the claim denial decision. The determination from the Plan must be made in the appeal decision, and this was 
not done in this case. As the Plan forfeited the opportunity to render an appeal decision, we find that there is no 
valid denial in this case. Therefore, we decided that the Plan has to pay for the services described by codes 
49440, 49441, and 99152.  
 
We also decided that the Plan does not have to pay for the services described by code 99153. 
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and 
that practice expenses are not payable to the physician for services provided in the facility setting.  
 
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the services described by code 99153. 
 
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.