Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99232 performed on 
November 2, and 4, 2022, and 99233 performed on November 3, 2022. We decided that the Plan does not have 
to pay for the services described by procedure code(s) 99223 performed on November 1, 2022, and 99239 
performed on November 21, 2022.  
 
You asked the Plan to pay for inpatient services coded as 99223, 99233, 99232 (2 units) and 99239 performed 
November 1, through November 21, 2022. You say that the inpatient services should be covered because they 
are supported in the record. The Plan says that 99223 performed on November 1, 2022, is not supported 
because records do not show a comprehensive history was completed. 99239 performed on November 21, 
2022, is not supported because the record does not include the amount of time spent on this service. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99232 performed on 
November 2, and 4, 2022, and 99233 performed on November 3, 2022.  
 
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) 99232 performed on November 
2, and 4, 2022, and 99233 performed on November 3, 2022.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 99223 
performed on November 1, 2022, and 99239 performed on November 21, 2022. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly with the CPT 
code that describes the services performed.  
 
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 described by procedure code 
99223 performed on November 1, 2022. Our reviewer says that code 99223 is not supported in the records. Our 
physician reviewer found 99223 requires 3 out of 3 of the following: a comprehensive history, a comprehensive 
examination, and medical decision making of high complexity. A comprehensive history requires a chief 
complaint, an extended history of present illness, a review of all additional body systems and a complete past, 
family and social history. A comprehensive examination requires a general multisystem examination or a 
complete examination of a single organ system and medical decision making of high complexity requires 2 out 
of 3 of an extensive number of diagnoses or management options, an extensive amount and complexity of data 
reviewed, and high risk of complication.  
 
Our physician reviewer also found that the provided records in this case do not document a comprehensive 
history including all elements: chief complaint, an extended history of present illness, a review of all additional 
body systems and a complete past, family and social history. Records in this case do include a general 
multisystem examination. Provided records in this case do not document 2 out of 3 of an extensive number of 
diagnoses or management options, an extensive amount and complexity of data reviewed, and high risk of 
complication. 
 We looked at this physician's review, the file, and Medicare rules. Regarding code 99239, the documentation 
does not indicate the time spent performing this service. It is required when reporting 99239 to document 31 or 
more minutes spent. Based on this information, we decided that Medicare rules for coverage of the services 
described by procedure code(s) 99223 performed on November 1, 2022, and 99239 performed on November 
21, 2022, have not been met. Therefore, we decided that the Plan does not have to pay for the services 
described by procedure code(s) 99223 performed on November 1, 2022, and 99239 performed on November 
21, 2022. 
 
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.