Appeal type: Surgery
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99222. We decided that the Plan does not have to pay 
for procedure code 27245.  
 
You asked the Plan to pay for procedure codes 99222 and 27245 provided on August 16, 2022. You say that 
you would like the Plan to reconsider their denial of payment. The Plan says that the records do not support the 
services billed.  
We decided that the Plan has to pay for procedure code 99222.  
 
The Plan must follow 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 99222 is Initial hospital care, per day, for the evaluation and management of a patient, which requires 
these 3 key components: A comprehensive history; A comprehensive examination; and medical decision 
making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified 
health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's 
and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 
minutes are spent at the bedside and on the patient's hospital floor or unit. 
 
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 procedure code 99222. Our reviewer says 
that the medical records support the billing of code 99222. Our physician reviewer found the August 16, 2022, 
consult cites the history of the present illness as well as the past medical history, past surgical history, 
medications, allergies, and social history. Therefore, the records do support that a comprehensive history was 
completed. The consult cites the examination included HEENT, lungs, cardiovascular, abdomen, and a detailed 
left lower extremity examination. Therefore, the records do support a comprehensive examination. The consult 
cites that x-ray images were reviewed, and a displaced left intertrochanteric femur fracture was shown. The 
treatment plan then was discussed at length and a decision was made for operative repair. The decision to 
undergo surgery is not of light complexity. After this decision was made, further coordination was needed with 
the operating room and staff. Therefore, the records do support medical decision-making of moderate 
complexity. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99222 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99222.  
 
We also decided that the Plan does not have to pay for procedure code 27245. 
 
The Plan must follow 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 27245 is Treatment of intertrochanteric, peritrochanteric, or subtrochanteric femoral fracture; with 
intramedullary implant, with or without interlocking screws and/or cerclage. 
 
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 procedure code 27245. Our reviewer says 
that the medical records do not support the billing of code 27245. Our physician reviewer found there was a 
consult performed on August 16, 2022, in which surgery was requested/recommended. The records DO support 
that the plan for such treatment WAS medically reasonable and necessary. However, the documentation does 
not support that this has been completed. Therefore, the records do not support the treatment of 
intertrochanteric, peri-trochanteric, or subtrochanteric femoral fracture, with an intramedullary implant. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 27245 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 27245. 
 
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.