Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99497 billed on January 10, 2023. We decided that the Plan does not 
have to pay for 99233 billed on January 10, 11, 12, and 13, 2023, and 99239 billed on January 14, 2023.  
 You asked the Plan to pay for the evaluation and management services described by codes 99497 and 99233 
billed on January 10, 2023, 99233 billed on January 11, 2023, January 12, 2023, and January 13, 2023, and 
99239 on January 14, 2023. You say that the evaluation and management services should be covered as billed 
because they are supported in the documentation. The Plan says that the evaluation and management services 
are denied because they are not supported in the documentation. 
 
We decided that the Plan has to pay for 99497 billed on January 10, 2023.  
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99497 is 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. 
 
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 the services at issue. Our reviewer says that the 
billing of 99497 on January 10, 2023, is supported in the documentation. Our physician reviewer found that it 
is documented that twelve minutes were spent in face-to-face discussion regarding the enrollees treatment 
wishes on January 10, 2023. 
 
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 service at issue have been met. Therefore, we decided that the Plan has to 
pay for 99497 billed on January 10, 2023.  
 
We also decided that the Plan does not have to pay for 99233 billed on January 10, 11, 12, and 13, 2023, 
and 99239 billed on January 14, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99233 is subsequent 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, 50 minutes must be met or exceeded. The CPT Code Manual definition of 99239 
is hospital inpatient or observation discharge day management; more than 30 minutes on the date of the 
encounter. 
 
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 the services at issue. Our reviewer says that 
99233 billed on January 10, through January 13, 2023, and 99239 billed on January 14, 2023, are not supported 
in the documentation. Our physician reviewer found that none of the documents for dates of service January 10, 
through 13, 2023, contain evidence of high complexity medical decision making. The documentation on 
January 14, 2023, is consistent with the preceding documentation, is not labeled as a discharge document, and 
does not establish that discharge occurred on the day that discharge services were billed, therefore 99239 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 the services at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 99233 billed on January 10, 11, 12, and 13, 2023, and 99239 billed on January 14, 
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.