Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99236. We decided that the Plan does not have to pay for 99291.  
 
You asked the Plan to pay for the evaluation and management services described by codes 99236 and 99291 
billed for date of service June 11, 2023. You say that 99236 and 99291 should be paid as billed because they 
are supported in the documentation. The Plan says that 99236 and 99291 are denied because they are not 
supported in the documentation 
 We decided that the Plan has to pay for 99236.  
 
The Plan follows Medicare rules. Medicare rules say that 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 99236 is hospital inpatient or observation care, for the 
evaluation and management of a patient including admission and discharge on the same date, 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, 85 minutes must be met or exceeded. 
 
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 item/service at issue. Our reviewer says 
that 99236 is supported in the provided documentation. Our physician reviewer found that documentation 
supports hospital admission for non-ST-elevation myocardial infarction (NSTEMI). The enrollee was 
discharged from the hospital to be transferred to new hospital. A medically appropriate history and physical 
were performed and there was high level of medical decision making. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 99236 have been met. Therefore, we decided that the Plan has to pay for 99236.  
 
We also decided that the Plan does not have to pay for 99291. 
 
The Plan follows Medicare rules. Medicare rules say that 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We looked at the file and Medicare rules. In this case we confirmed that while the provided records do contain 
documentation of critical care evaluation and management services performed on June 11, 2023, the records 
indicate these services were rendered by a physican other than the rendering provider listed on the claim. 
Therefore, 99291 cannot be verified. Based on this information, we decided that Medicare rules for coverage of 
99291 have not been met. Therefore, we decided that the Plan does not have to pay for 99291. 
 
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.