Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services on March 3, 2022. We decided that the Plan does not 
have to pay for the rest of the services.  
 
You asked the Plan to pay for hospital care (procedure code 99233) rendered from March 3, 2022, to March 6, 
2022.. You say that this should be paid for. The Plan says that Current Procedural Terminology (CPT) code 
99233 (1 unit) remains not supported 
 We decided that the Plan has to pay for the services on March 3, 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 definition of CPT 99223 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 the services. Our reviewer says that on March 3, 
2022, the interval examination was detailed. The medical decision making was of high complexity. CPT 99233 
was supported. 
 
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 3, 2022.  
 
We also decided that the Plan does not have to pay for the rest of the services. 
 
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 the rest of the services. Our reviewer says that on 
March 4, 2022, March 5, 2022, and March 6, 2022, the interval histories were only problem focused, rather 
than detailed. The medical decision making was additionally not 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 rest of the services have not been met. Therefore, we decided that the Plan 
does not have to pay for the rest of the services. 
 
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.