Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99233 billed on April 29, 
2023. We decided that the Plan does not have to pay for the services described by procedure code(s) 99233 
billed on April 30, 2023, May 1, 2023, and May 2, 2023.  
 
You asked the Plan to pay for the evaluation and management services coded as 99233 billed on April 29, 
2023, April 30, 2023, May 1, 2023, and May 2, 2023. You say that 99233 billed on April 29, 2023, through 
May 2, 2023, should be covered because documentation supports this service for each date billed. The Plan 
says that 99233 billed on April 29, 2023, is being handled as an original decision reopen for New and Material 
Evidence, therefore no coverage decision was made. Units of 99233 billed on April 30, 2023, through May 2, 
2023, are denied because they are not supported in the record. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99233 billed on 
April 29, 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(s) 99233 billed on April 29, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 99233 
billed on April 30, 2023, May 1, 2023, and May 2, 2023. 
 
 The Plan follows Medicare rules. Medicare rules say that providers/suppliers must report services correctly.  
 
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) 
99233 billed on April 30, 2023, May 1, 2023, and May 2, 2023. Our reviewer says that these units of 99233 are 
not supported in the documentation. Our physician reviewer found the enrollees acute condition 
(hyponatremia) had stabilized by April 30, 2023. Daily care on April 30, 2023, May 1, 2023, and May 2, 2023, 
focused on maintenance and monitoring. The medical decision making was no longer of high complexity. 
 
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) 99233 billed on April 30, 2023, 
May 1, 2023, and May 2, 2023 have not been met. Therefore, we decided that the Plan does not have to pay for 
the services described by procedure code(s) 99233 billed on April 30, 2023, May 1, 2023, and May 2, 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.