Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99223 billed on April 1, 2023, and 99233 billed on April 2, 2023. We 
decided that the Plan does not have to pay for 99233 billed on April 3, 2023.  
 You asked the Plan to pay for the evaluation and management services described by codes 99223 billed on 
April 1, 2023, 99233 billed on April 2, 2023, and 99233 billed on April 3, 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 the evaluation and management services are denied because they are not supported in the 
documentation. 
 
We decided that the Plan has to pay for 99223 billed on April 1, 2023, and 99233 billed on April 2, 2023.  
 
The Plan follows 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 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, 75 minutes must be met or exceeded.  
 
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. 
 
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 99223 billed on April 1, 2023, and 99233 
billed on April 2, 2023. Our reviewer says that 99223 billed on April 1, 2023, and 99233 billed on April 2, 
2023, are supported in the documentation. Our physician reviewer found that the provided records for April 1, 
2023, document a 68-year-old with an acute stroke who underwent thrombectomy and is requiring further 
evaluation with a transthoracic echocardiogram, a magnetic resonance brain scan, a transesophageal 
echocardiogram, and a follow-up computed tomography scan. Provided records document a medically 
appropriate history and/or examination and 2 out of 3 of an extensive number of diagnoses or management 
options, an extensive amount and complexity of data reviewed and high risk of complication. Criteria for CPT 
99223 are met. Regarding 99233 billed on April 2, 2023, records document review of a computed tomography 
scan showing hemorrhagic conversion of the stroke requiring neurosurgical consultation and medication 
adjustment (holding aspirin), records document review of laboratory tests, arterial blood gases and a chest 
radiograph. Provided records document a medically appropriate history and/or examination and 2 out of 3 of an 
extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed 
and high risk of complication. Criteria for CPT 99233 are met. 
 
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 item/service at issue have been met. Therefore, we decided that the Plan has 
to pay for 99223 billed on April 1, 2023, and 99233 billed on April 2, 2023.  
 
We also decided that the Plan does not have to pay for 99233 billed on April 3, 2023. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
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 99233 billed on April 3, 2023. Our 
reviewer says that 99233 billed on April 3, 2023, is not supported in the documentation. Our physician 
reviewer found that records document review of another computed tomography scan of the head showing a 4-
millimeter shift and review of a transthoracic echocardiogram and no other new data or treatment plans. 
Records do not document 2 out of 3 of an extensive number of diagnoses or management options, an extensive amount and complexity of data reviewed and high risk of complication. Criteria for CPT 99233 are not met.  
 
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 item/service at issue have not been met. Therefore, we decided that the Plan 
does not have to pay for 99233 billed on April 3, 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.