Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99223. We decided that the Plan does not have to pay for 99233.  
 
You asked the Plan to pay for hospital care (procedure codes 99223, 99233) rendered on May 1, 2022, and 
May 2, 2022.. You say that this should be paid for. The Plan says that the documentation does not support this 
level of care. 
 
We decided that the Plan has to pay for 99223.  
 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 99223 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 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." 
 
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. Our reviewer found that on May 1, 
2022, the documentation indicates the evaluation and management of the member did contain the 3 
components including a comprehensive history and physical exam and medical decision making of high 
complexity. 
 
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 
99223.  
 
We also decided that the Plan does not have to pay for 99233. 
 
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 99233 is "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 99233. Our reviewer says that on May 2, 
2022, the provider failed to complete a comprehensive history and the plan of care did not include decision 
making of high complexity. The enrollee had stabilized and improved overnight and there were no new 
complications. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99233 have not been met. Therefore, we decided that the Plan does not have to 
pay for 99233. 
 
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.