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 complexity (CPT 99285) provided on October 1, 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 complexity (CPT 99285). You say that the billed CPT code 99285 is supported by the medical records provided. The Plan denied your request. The Plan says 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 complexity (CPT 99285) is not medically 
necessary. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 complexity (CPT 99285). Our reviewer says 
that 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 
complexity (CPT 99285) is not medically necessary. Our reviewer found that the enrollee was a then,  
58-year-old who presented to the emergency department (ED) on October 1, 2022, with left lower quadrant 
(LLQ) pain. The enrollee was evaluated with a history and physical exam and laboratory studies. The enrollee 
was diagnosed with acute pyelonephritis and treated with antibiotics and analgesics. The enrollee was 
discharged home with an antibiotic prescription. The review has determined that CPT 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 complexity (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 
complexity (CPT 99285) provided on October 1, 2022.