Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code 99232 billed for date of 
service April 11, 2023. We decided that the Plan does not have to pay for the services described by procedure 
code 99223 billed for date of service April 10, 2023.  
 
You asked the Plan to pay for procedure code 99223 billed for date of service April 10, 2023. You say that 
medical records were provided. The Plan says that the billed code is not supported. 
 
We decided that the Plan has to pay for the services described by procedure code 99232 billed for date of 
service April 11, 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 99232 billed for date of service 
April 10, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code 99223 
billed for date of service April 10, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
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. 
 
We looked at the file and Medicare rules. The records do show that an appropriate history and exam were 
provided. The records do not show that a high level of medical decision making was provided. Based on this 
information, we decided that the Medicare rules for coverage have not been met. Therefore, we decided that the 
Plan does not have to pay for the services described by procedure code 99223 billed for date of service 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.