Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 99152 on DOS May 4, 2023, and 99232 on DOS May 7, 2023. 
We decided that the Plan does not have to pay for codes 99153, 93010, and 99223 on DOS May 4, 2023, and 
code 99233 on DOS May 6, 2023.  
 
You asked the Plan to pay for the medical services provided on dates of service (DOS) May 4, 2023, through 
May 7, 2023, billed with codes 99152, 99153, 99223, 93010, 99233, and 99232. You say that the services were 
billed correctly and are supported by the records submitted. The Plan says that the denial of payment was 
correct for the codes at issue. 
 
We decided that the Plan has to pay for codes 99152 on DOS May 4, 2023, and 99232 on DOS May 7, 
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 code 99152. 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. 
 
The Plan also has not made reasonable and diligent efforts to gather and forward to us information regarding 
their decision to deny code 99232. The rationale indicated by the Plan for this code states that it was not billed 
with an appropriate modifier due to an NCCI edit. However, review of the file does not show any other code 
with which 99232 has an NCCI edit for this DOS. As such, this denial is not supported. Therefore, we decided 
that the Plan has to pay for codes 99152 on DOS May 4, 2023, and 99232 on DOS May 7, 2023.  
 
We also decided that the Plan does not have to pay for codes 99153, 93010, and 99223 on DOS May 4, 
2023, and code 99233 on DOS May 6, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that code 99153 cannot be 
paid separately for services in the facility setting. 
 
We looked at the file and Medicare rules. We confirmed that code 99153 was billed in the facility setting. As 
such, this cannot be separately paid. Regarding 93010, this was billed on the same DOS as 93454, with which it 
has a Column 1/Column 2 relationship. 93010 was not billed with an appropriate modifier. For 99233, this is 
also a Column 2 code in relation to code 93454 and was also not billed with an appropriate modifier. Lastly, 
regarding code 99233, this was billed on the same date of service as 99291. The file only includes one progress 
note for this DOS, which does not support payment for two evaluation and management codes. As such, 
payment for 99223 is not supported. 
 
Based on this information, we decided that Medicare rules for coverage of codes 99153, 93010, and 99223 on 
DOS May 4, 2023, and code 99233 on DOS May 6, 2023 have not been met. Therefore, we decided that the 
Plan does not have to pay for codes 99153, 93010, and 99223 on DOS May 4, 2023, and code 99233 on DOS 
May 6, 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.