Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99497 and 99498. We decided that the Plan does not have to pay for 
99222 and 99233.  
 
You asked the Plan to pay for procedure codes 99222, 99223, 99497, and 99498 rendered from January 27, 
2023, to January 28, 2023.. 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 99497 and 99498.  
 
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 overturned codes is: 
 
CPT 99497: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate 
 
CPT 99498: 
 
Advance care planning including the explanation and discussion of advance directives such as standard forms 
(with completion of such forms, when performed), by the physician or other qualified health care professional; 
each additional 30 minutes (List separately in addition to code for primary procedure) 
 
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 these codes. Our reviewer says that the 
documentation does support that advance care planning was performed with documented times for care 
planning of 49 minutes and 32 minutes, separately, so CPT 99497 and 99498 are both 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 
99497 and 99498.  
 
We also decided that the Plan does not have to pay for 99222 and 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. The definition of the upheld codes is: 
 
CPT 99222: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and moderate level of medical decision making. 
When using total time on the date of the encounter for code selection, 55 minutes must be met or exceeded 
 
CPT 99223: 
 
Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which 
requires a medically appropriate history and/or examination and high level of medical decision making. When 
using total time on the date of the encounter for code selection, 75 minutes must be met or exceeded 
 
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 these codes. Our reviewer says that in terms of CPT 
99222, the documentation supports an appropriate exam, but not an appropriate history or medical decision 
making of moderate, or 55 minutes or more spent on care, so CPT 99222 is not supported. 
 
In terms of CPT 99233, the documentation supports an appropriate exam, but not an appropriate history or 
medical decision making of high level, so CPT 99233 is not 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 99222 and 99233 have not been met. Therefore, we decided that the Plan does 
not have to pay for 99222 and 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.