Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99233 billed for dates of 
service April 11, 2023, and April 12, 2023, and 99232 billed for dates of service April 13, 2023, and April 14, 
2023. We decided that the Plan does not have to pay for the services described by procedure code(s) 99222 
billed on April 10, 2023.  
 
You asked the Plan to pay for the evaluation and management services described by codes 99222, 99233 (2 
units), and 99232 (2 units) billed April 10, 2023, through April 14, 2023. You say that the evaluation and 
management services should be paid as billed because they are supported in the documentation. The Plan says 
that 99222 for date of service April 10, 2023, is not supported in the documentation. 99233 billed for dates of 
service April 11, 2023, and April 12, 2023, and 99232 billed for dates of service April 13, 2023, and April 14, 
2023, were handled as an original decision reopen for New and Material Evidence, therefore no appeal decision 
was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99233 billed for 
dates of service April 11, 2023, and April 12, 2023, and 99232 billed for dates of service April 13, 2023, 
and April 14, 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) 99233 billed for dates of 
service April 11, 2023, and April 12, 2023, and 99232 billed for dates of service April 13, 2023, and April 14, 
2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 99222 
billed on April 10, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
 
We looked at the file and Medicare rules. We were able to confirm that the record does not contain an 
evaluation and management note with the date of service listed as April 10, 2023. There is evidence in the 
provided documentation that an exam took place on April 15, 2023, or after. The documentation states the 
enrollee had an echocardiography done on April 11, 2023, and is described as status post cardioversion, which 
took place on April 12, 2023. The documentation also contains lab results through April 15, 2023. There is no 
evidence in the records provided that an exam was done on April 10, 2023. Based on this information, we 
decided that Medicare rules for coverage of the services described by procedure code(s) 99222 have not been 
met. Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
99222 billed on April 10, 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.