Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 93226. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 93229.  
 
You asked the Plan to pay for mobile cardiovascular telemetry services coded as 93226 for date of service 
April 11, 2023, and mobile cardiovascular telemetry services coded as 93229 for date of service April 12, 
2023.. You say that codes 93229 and 93226 are supported in the documentation and were medically necessary.  
The Plan says that code 93229 is not supported in the documentation. The Plan says code 93226 was handled 
as an original decision reopen clerical error under another case number, therefore no appeal decision was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 93226.  
 
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) 93226.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
93229. 
 
The Plan must follow Medicare rules. The rules say that providers must report services correctly with the CPT 
code that describes the services performed.  
 
The records provided do not include sufficient detail to support code 93229, defined as external mobile 
cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis 
and greater than 24 hours of accessible electrocardiogram data storage (retrievable with query) with 
electrocardiogram triggered and patient selected events transmitted to a remote attended surveillance center for 
up to 30 days; technical support for connection and patient instructions for use, attended surveillance, analysis 
and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care 
professional. Records do not contain evidence of real time data analysis. The records do not contain enough 
detail to support that monitoring by a technician was performed. Therefore, we decided that the Plan does not 
have to pay for the services described by procedure code(s) 93229. 
 
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.