Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (99223) and subsequent hospital care 
(99233) provided from February 28, 2022, through March 1, 2022. 
 
You asked the Plan to pay for the services. You say that this service was warranted and medically necessary. 
You say that the attached medical records support the claim as originally billed. The Plan denied your request. 
The Plan says the services are not supported. 
 
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 99223 is initial hospital care, per day, for the evaluation 
and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity.  Counseling and/or coordination of care with other physicians, other qualified health care professionals, or 
agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. 
Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside 
and on the patient's hospital floor or unit. The definition of code 99233-subsequent hospital care, per day, for 
the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed 
interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or 
coordination of care with other physicians, other qualified health care professionals, or agencies are provided 
consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is 
unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are 
spent at the bedside and on the patient's hospital floor or unit. 
 
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. Our reviewer found the 
provided documentation from February 28, 2022, describes the enrollee reporting having a great toe infection 
having been taking oral antibiotics given by a podiatrist. The enrollee was given pain medication and x-ray 
showed possible gas gangrene but no osteomyelitis. Podiatry was contacted. The physical examination was 
basic and focused on the extremities including the great toe. A second note from March 1, 2022, had another 
brief history describing the patient feeling well. Physical findings were also basic and focused on the toe. Each 
of these notes did not sufficiently describe a comprehensive history or physical and each did not sufficiently 
show medical decision-making of high complexity as the patient was stable and did not have complications. 
 
We looked at this physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for initial hospital care (99223) and subsequent hospital care (99233) provided from February 28, 
2022, through March 1, 2022.