Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency department visit for the evaluation and 
management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive 
examination; and medical decision making of high decision making (CPT 99285) provided on 
September 4, 2022. 
 
You asked the Plan to pay for the emergency department visit for the evaluation and management of a patient, 
which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical 
condition and/or mental status: A comprehensive history; A comprehensive examination; and medical decision making of high decision making (CPT 99285). You say that the correct code was billed. The Plan denied your 
request. The Plan says the code billed is not medical necessary. 
 
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 99285 is emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components within the constraints imposed by the 
urgency of the patient's clinical condition and/or mental status: a comprehensive history; a comprehensive 
examination; and medical decision making of high level. 
 
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 emergency department visit for the 
evaluation and management of a patient, which requires these 3 key components within the constraints imposed 
by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A 
comprehensive examination; and medical decision making of high decision making (CPT 99285). Our reviewer 
says that the services at issue in this case were not supported by the medical records. Our physician reviewer 
found that the enrollee was a then, 77-year-old with a history of HTN, Anxiety, COVID-19, and single kidney 
who presented to the emergency department (ED) on September 4, 2022, with upper abdominal pain 
unresponsive to Prilosec and Mylanta. The enrollee was evaluated with a history and physical exam, laboratory 
studies, EKG, CXR, and CT scan of the abdomen/pelvis. She was treated with IV Dialudid, IV Hydralazine, 
and IV fluids. She was diagnosed with gastritis and discharged home. The review has determined that code 
99284 was more appropriate in this case. There was no decision making of high complexity. the presenting 
problems were not of high severity, posing an immediate significant threat to life and physiologic function. 
 
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 emergency department visit for the evaluation and management of a patient, 
which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical 
condition and/or mental status: A comprehensive history; A comprehensive examination; and medical decision 
making of high decision making (CPT 99285) have not been met. Therefore, we decided that the Plan does not 
have to pay for an emergency department visit for the evaluation and management of a patient, which requires 
these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or 
mental status: A comprehensive history; A comprehensive examination; and medical decision making of high 
decision making (CPT 99285) provided on September 4, 2022.