Appeal type: Inpatient Hospital
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 99231 billed on May 10, 
2023, and 99231 billed on May 11, 2023. We decided that the Plan does not have to pay for the services 
described by procedure code(s) 99222 billed on March 23, 2023, 99231 billed on March 27, 2023, 99231 billed 
on March 29, 2023, 99231 billed on March 31, 2023, 99231 billed on April 3, 2023, and 99231 billed on April 
6, 2023.  
 
You asked the Plan to pay for the evaluation and management services coded as 99222 billed on March 23, 
2023, 99231 billed on March 27, 2023, 99231 billed on March 29, 2023, 99231 billed on March 31, 2023, 
99231 billed on April 3, 2023, 99231 billed on April 6, 2023, 99231 billed on May 10, 2023, and 99231 billed 
on May 11, 2023. You say that these evaluation and management services should be paid as billed because the 
date of service for each is clearly listed on the documentation. The Plan says that 99222 billed on March 23, 
2023, 99231 billed on March 27, 2023, 99231 billed on March 29, 2023, 99231 billed on March 31, 2023, 
99231 billed on April 3, 2023, and 99231 billed on April 6, 2023, are denied because the procedure notes for 
each do not include the actual date of service. 99231 billed on May 10, 2023, and 99231 billed on May 11, 
2023, are being handed as an original decision reopen for New and Material Evidence, therefore no coverage 
decision was made. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 99231 billed on May 
10, 2023, and 99231 billed on May 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(s) 99231 billed on May 10, 2023, 
and 99231 billed on May 11, 2023.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 99222 
billed on March 23, 2023, 99231 billed on March 27, 2023, 99231 billed on March 29, 2023, 99231 billed 
on March 31, 2023, 99231 billed on April 3, 2023, and 99231 billed on April 6, 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 looked at the file and Medicare rules. We confirmed that while there are evaluation and management notes 
in the provided documentation, records do not contain any evaluation and management notes with the date of 
service listed as March 23, 2023, March 27, 2023, March 29, 2023, March 31, 2023, April 3, 2023, or April 6, 2023. Per Medicare rules, the signed date, charted date, dictated date, transcribed date, admit date or discharge 
date isn't sufficient to verify the actual date of service. As such, the evaluation and management services billed 
for these dates are not supported. Based on this information, we decided that Medicare rules for coverage of the 
services described by procedure code(s) 99222 billed on March 23, 2023, 99231 billed on March 27, 2023, 
99231 billed on March 29, 2023, 99231 billed on March 31, 2023, 99231 billed on April 3, 2023, and 99231 
billed on April 6, 2023, have not been met. Therefore, we decided that the Plan does not have to pay for the 
services described by procedure code(s) 99222 billed on March 23, 2023, 99231 billed on March 27, 2023, 
99231 billed on March 29, 2023, 99231 billed on March 31, 2023, 99231 billed on April 3, 2023, and 99231 
billed on April 6, 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.