Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for critical care provided on March 17, 2023, billed with code 99291. We 
decided that the Plan does not have to pay for the subsequent hospital inpatient or observation care provided on 
March 20, 2023, billed with code 99233.  
You asked the Plan to pay for critical care and subsequent hospital inpatient or observation care provided from 
March 17, 2023, to March 20, 2023, billed with codes 99291 and 99233. You say that the medical records 
submitted support codes 99233 and 99291 and should be paid. The Plan says that the records submitted do not 
document critical care or evaluation of the critically ill or critical injury, first 30-74 minutes. The Plan says that 
the records do not document subsequent hospital inpatient or observation care which requires medically 
appropriate history or examination and high-level decision making to support code 99233. Therefore, both 
codes 99291 and 99233 remains not supported. 
 
We decided that the Plan has to pay for critical care provided on March 17, 2023, billed with code 99291.  
 
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 to pay for critical care (99291) and subsequent hospital 
inpatient or observation care (99233). Our physician reviewer found the medical records submitted documents 
the patient was in critical care, and time spent was 40 minutes which support code 99291. The records also 
support that the examination was appropriate; however, the documentation did not include an appropriate 
history or high-level medical decision making to support code 99233. Code 99233 remains 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 critical care (99291) have been met. Therefore, we decided that the Plan has to 
pay for critical care provided on March 17, 2023, billed with code 99291.  
 
We also decided that the Plan does not have to pay for subsequent hospital inpatient or observation care 
provided on March 20, 2023, billed with code 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. 
 
As noted above, our physician reviewer found that code 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 subsequent hospital inpatient or observation care (99233) have not been met. 
Therefore, we decided that the Plan does not have to pay for subsequent hospital inpatient or observation care 
provided on March 20, 2023, billed with code  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.