Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 93229. We decided that the Plan does not have to pay 
for procedure code 99212-25.  
 
You asked the Plan to pay for practitioner services provided on March 30, 2023, billed with procedure codes 
93229 and 99212-25. You say that the claim is billed correctly and should be paid. The Plan says that 
documentation does not support the billed codes.  
We decided that the Plan has to pay for procedure code 93229.  
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
We asked our coding 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 code 93229. Our reviewer says that that the 
documentation supports code 93229 but does not support code 99212-25. Our physician reviewer found that 
the records include an external mobile cardiovascular telemetry with electrocardiographic (ECG) recording, 
concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage 
(retrievable with query) with ECG triggered and patient selected events transmitted to a remote attended 
surveillance center for up to 30 days; technical support for connection and patient instructions for use, attended 
surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other 
qualified health care professional for the date of service and an electronically signed physician's order.  
Provided records in this case do not support procedure code 99212-25 as the records do not include an 
evaluation and management visit note dated March 30, 2023.  
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 93229 have been met. Therefore, we decided that the Plan has to pay for 
procedure code 93229.  
 
We also decided that the Plan does not have to pay for procedure code 99212-25. 
 
The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly. 
Procedures should be reported with the Current Procedural Terminology (CPT) code that describes the services 
performed.  
 
We asked our coding 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 99212-25. Our reviewer says 
that that the documentation supports code 93229 but does not support code 99212-25. Our physician reviewer 
found that the records include an external mobile cardiovascular telemetry with electrocardiographic (ECG) 
recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data 
storage (retrievable with query) with ECG triggered and patient selected events transmitted to a remote 
attended surveillance center for up to 30 days; technical support for connection and patient instructions for use, 
attended surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician 
or other qualified health care professional for the date of service and an electronically signed physician's order.  
Provided records in this case do not support procedure code 99212-25 as the records do not include an 
evaluation and management visit note dated March 30, 2023.  
  
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99212-25 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 99212-25. 
 
 
 
 
 
 
 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.