Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for 99223 on May 17, 2023. We decided that the Plan does not have to pay 
for 99222 on May 18, 2023.  
 
You asked the Plan to pay for procedure codes 99222 and 99223 rendered from May 17, 2023, to May 18, 
2023. You say that this should be paid for. The Plan says that the records do not support the services billed. 
 
We decided that the Plan has to pay for 99223 on May 17, 2023.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 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 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 for CPT 99223. Our reviewer says that the records 
support a medically appropriate history/examination, and a high level of medical decision making for May 17, 
2023. 
 
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 on May 17, 2023.  
 
We also decided that the Plan does not have to pay for 99222 on May 18, 2023. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The definition of CPT 99222 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 moderate level of medical decision making. When using 
total time on the date of the encounter for code selection, 55 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 for CPT 99222. Our physician reviewer found the 
records do not support using an initial care code on May 18, 2023. This was subseqeuent care. 
 
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 99222 on May 18, 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.