Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99239. We decided that the 
Plan does not have to pay for the services described by procedure code(s) 99223.  
 
You asked the Plan to pay for inpatient evaluation and management (EM) services provided on August 12, 
2022, billed with code 99223. . You say that the claim was billed correctly and should be paid. The Plan says 
that the medical records submitted don't support a comprehensive history. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99239.  
 
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) 99239.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99223. 
 
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 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 services described by procedure code(s) 
99223. Our reviewer says that documentation does not support the billed code. Our physician reviewer found 
the enrollee is a 91-year-old male who was treated in the hospital on August 12,2022. Documentation from that 
date describes the enrollee with recent trip and fall landing on elbow and hip. He denied other symptoms, did 
not hit his head, was able to ambulate after the fall, but has right hip pain. Physical examination was detailed 
and included no tenderness, no deformity. Labs showed mild anemia. X-ray showed pubic rami fracture. Rehab 
was prescribed. Although the documentation showed a detailed history and physical, there was insufficient 
support for medical decision-making of high complexity as the patient was stable hemodynamically without 
complications and no planned procedures or invasive treatments were needed. Therefore, the documentation 
does not sufficiently support procedure code 99223. . 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services described by procedure code(s) 99223 have not been met. 
Therefore, we decided that the Plan does not have to pay for the services described by procedure code(s) 
99223. 
 
 
 
 
 
 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.