Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for CPT 99223 on June 10, 2022. We decided that the Plan does not have 
to pay for CPT 99233 from June 11, 2022, to June 12, 2022.  
 You asked the Plan to pay for hospital care (procedure code 99223 and 99233) rendered from June 10, 2022, to 
June 12, 2022.. You say that this should be paid for. The Plan says that the documents do not support this level 
of care. 
 
We decided that the Plan has to pay for CPT 99223 on June 10, 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. The definition of the codes at issue are: 
CPT 99223: 
 
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 high 
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 high severity. Typically, 70 minutes are 
spent at the bedside and on the patient's hospital floor or unit 
 
CPT 99233: 
 
Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of 
these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high 
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 patient is unstable or has developed a significant complication or a significant new 
problem. Typically, 35 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 99223 on June 10, 2022. Our reviewer says 
that this code is supported. The entirety of the records from the nurse practitioner and physician includes a 
comprehensive history, comprehensive examination and high-complexity medical decision making. 
 
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 
CPT 99223 on June 10, 2022.  
 
We also decided that the Plan does not have to pay for CPT 99233 from June 11, 2022, to June 12, 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 99233 from June 11, 2022, to June 12, 2022. 
Our reviewer says that CPT 99233 on 6/11/2022 is not supported. The interval history is not comprehensive, 
and the medical decision making is without change/high complexity. CPT 99233 on 6/12/2022 is not 
supported.  No records for this date of service have been submitted. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPT 99233 from June 11, 2022, to June 12, 2022, have not been met. 
Therefore, we decided that the Plan does not have to pay for CPT 99233 from June 11, 2022, to June 12, 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.