Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99223 billed on June 8, 
2023, and 99232 billed on June 9, 2023. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 99239-GC-AQ billed on June 10, 2023.  
 
You asked the Plan to pay for the evaluation and management services coded as 99223 billed on June 8, 2023, 
99232 billed on June 9, 2023, and 99239-GC-AQ billed on June 10, 2023. You say that the evaluation and 
management services should be paid as billed because they are supported in the documentation. The Plan says 
that 99223 billed on June 8, 2023, and 99232 billed on June 9, 2023, are being handled as an original decision 
reopen for New and Material Evidence, therefore no coverage decision was made. 99239-GC-AQ is denied 
because only 1 unit of this code may be reported per calendar date.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 99223 billed on date 
of service June 8, 2023, and 99232 billed on June 9, 2023.  
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 99223 billed on date of service 
June 8, 2023, and 99232 billed on June 9, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99239-GC-AQ billed on June 10, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that a practitioner shall only bill 1 inpatient or observation 
discharge code, as appropriate, once per calendar date. 
 
We looked at the file and Medicare rules. We confirmed that 2 units of code 99239 were billed on the same 
date of service, June 10, 2023. The Plan has agreed to overturn 1 unit of 99239 for payment. Per Medicare 
rules, a provider may only bill 1 hospital inpatient or observation care code per calendar date. Based on this 
information, we decided that Medicare rules for coverage of the services described by procedure code(s) 99239 
billed on June 10, 2023, have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99239-GC-AQ billed on June 10, 2023. 
 
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.