Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99223 billed on May 4, 
2023, and 99233 billed on May 6, 2023. We decided that the Plan does not have to pay for the services 
described by procedure code 99233 billed on May 7, 2023.  
 
You asked the Plan to pay for the evaluation and management services coded as 99223 billed on May 4, 2023, 
99233 billed on May 6, 2023, and 99233 billed on May 7, 2023. You say that the evaluation and management 
services billed on May 4, 2023, through May 7, 2023, should be paid as billed because they are supported in 
the documentation. The Plan says that 99223 billed on May 4, 2023, and 99233 billed on May 6, 2023, are 
being handled as an original decision reopen for New and Material Evidence, therefore no coverage decision 
has been made. 99233 billed on May 7, 2023, is denied because it is not supported in the record. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99223 billed on May 
4, 2023, and 99233 billed on May 6, 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 May 4, 2023, 
and 99233 billed on May 6, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99233 
billed on May 7, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
We looked at the file and Medicare rules. In this case, we confirmed that the provided documentation does not 
include an evaluation and management note for date of service May 7, 2023. As such, 99233 billed on this date 
of service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 99233 billed on May 7, 2023. have not been met. Therefore, we 
decided that the Plan does not have to pay for the services described by procedure code 99233 billed on May 7, 
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.