Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99454. We decided that the Plan does not have to pay for 99457 and 
99458.  
 
You asked the Plan to pay for practitioner services provided on March 31, 2023, billed with procedure codes 
99454, 99457, and 99458 (x3). You say that the claim is billed correctly and should be paid. The Plan says that 
documentation does not support the billed codes.  
We decided that the Plan has to pay for 99454.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that for CPT 99454, the 
provider supplies the patient with remote physiologic monitoring equipment and receives daily recordings 
and/or programmed alerts. This was documented in medical record and therefore should be covered. Medical 
record does not include sufficient documentation to support treatment management services. For CPT 99457 
the provider monitors a patient's remote physiologic recordings and/or programmed alerts and interacts with the 
patient or caregiver to adjust treatment based on the recordings (first 20 minutes). This service was not found in 
medical record. For CPT 99458 the provider monitors a patient's remote physiologic recordings and/or 
programmed alerts and interacts with the patient or caregiver to adjust treatment based on the recordings 
(additional 20 minutes). This service was not found in medical record. 
  
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 99454.  
 
We also decided that the Plan does not have to pay for 99457 and 99458. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed. 
 
We asked our coding reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the item/service at issue. Our reviewer says 
that documentation partially supports the billed codes. Our physician reviewer found that for CPT 99454, the 
provider supplies the patient with remote physiologic monitoring equipment and receives daily recordings 
and/or programmed alerts. This was documented in medical record and therefore should be covered. Medical 
record does not include sufficient documentation to support treatment management services. For CPT 99457 
the provider monitors a patient's remote physiologic recordings and/or programmed alerts and interacts with the 
patient or caregiver to adjust treatment based on the recordings (first 20 minutes). This service was not found in 
medical record. For CPT 99458 the provider monitors a patient's remote physiologic recordings and/or 
programmed alerts and interacts with the patient or caregiver to adjust treatment based on the recordings 
(additional 20 minutes). This service was not found in medical record. 
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 99457 and 99458. 
 
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.