Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services coded 99232 provided on December 19, 2022, and the 
services coded 99233 and 99238 provided on December 23, 2022. We decided that the Plan does not have to 
pay for the billed codes 00731, 99100, 71045, 99284 and 99222.  
 
You asked the Plan to pay for the services coded 99232 provided on December 19, 2022, and the services 
coded 99233 and 99238 provided on December 23, 2022. You say that you would like this claim reprocessed 
based on the medical records. The Plan says that these codes have denied correctly. 
 
We decided that the Plan has to pay for the services coded 99232 provided on December 19, 2022, and 
the services coded 99233 and 99238 provided on December 23, 2022.  
 
The Plan follows Medicare rules. The rules say that claims or claim lines that have been determined to be exact 
duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, no claim forms were submitted for 
99233 and 99238 that were provided on December 23, 2022. In addition, the Plan has denied payment for 
99232 provided on December 19, 2022, stating that the original claim is in process. There is no information 
regarding further info on what appeal this code is located in or if a decision has been rendered. The Plan has 
failed to substantiate their denial. Therefore, we decided that the Plan has to pay for the services coded 99232 
provided on December 19, 2022, and the services coded 99233 and 99238 provided on December 23, 2022.  
 
We also decided that the Plan does not have to pay for the billed codes 00731, 99100, 71045, 99284 and 
99222. 
 
The Plan follows Medicare rules. The Plan must follow Medicare rules. The rules say that claims or claim lines 
that have been determined to be exact duplicates of another claim or claim line are denied. However, such 
denials may be appealed. Medicare rules say that providers must report services correctly. Providers must 
report services with the appropriate procedure code. 
 
We looked at the file and Medicare rules. The file includes evidence that coded 71045, 99284, and 99222 at 
issue were reimbursed by the Plan. Comparison of these claims shows these are exact duplicates that have previously been processed. There is no evidence presented to support that the billed items/services were 
provided twice on the same date. In addition, we find that procedure code 99100 has a status indicator of B on 
the Physician Fee Schedule. This means that procedure code 99100 is not separately payable. Finally, we have 
confirmed that code 00731 is a column II code to column I code 43255 with a modifier indicator of 0. The 
column II code is therefore not payable. Based on the claim submitted, Medicare billing criteria have not been 
met. Therefore, we decided that the Plan does not have to pay for the billed codes 00731, 99100, 71045, 99284 
and 99222. 
 
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.