Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 99291 billed for date of service July 20, 2022. We 
decided that the Plan does not have to pay for procedures codes 99233 and 99239 billed for dates of service 
July 21, 2022, to July 24, 2022.  
 
You asked the Plan to pay for procedure codes 99291, 99233, and 99239 billed for dates of service July 20, 
2022, to July 24, 2022. You say that the services were medically necessary. The Plan says that the billed codes 
are not verified. 
 
We decided that the Plan has to pay for procedure code 99291 billed for date of service July 20, 2022.  
 
The Plan must follow Medicare rules. Medicare rules say 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 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 procedure code 99291 billed for date of service July 20, 2022. Our physician reviewer found 
that the documentation does support that 45 minutes of critical care was provided on July 20, 2022. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99291 have been met. Therefore, we decided that the Plan has 
to pay for procedure code 99291 billed for date of service July 20, 2022.  
 
We also decided that the Plan does not have to pay for procedures codes 99233 and 99239 billed for dates 
of service July 21, 2022, to July 24, 2022. 
 
The Plan must follow Medicare rules. Medicare rules say 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 99233 is subsequent hospital inpatient or observation 
care, per day, for the evaluation and management of a patient, 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, 50 minutes must be met or exceeded. 
 
The CPT Code Manual definition of code 99239 is hospital inpatient or observation discharge day 
management; more than 30 minutes on the date of the encounter. 
 
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 procedures codes 99233 and 99239 billed for 
dates of service July 21, 2022, to July 24, 2022. Our physician reviewer found that the documentation does not 
support a high complexity of medical decision making was provided from July 21-23, 2022. The 
documentation does not support that more than 30 minutes were spent with the enrollee for discharge on July 
24, 2022.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedures codes 99233 and 99239 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedures codes 99233 and 99239 billed for dates of service July 21, 
2022, to July 24, 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.