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 the following 3 components: a detailed history; a detailed 
examination; and medical decision making of moderate complexity (code 99284) provided on  
September 25, 2022. 
 
You asked the Plan to pay for an emergency department visit for the evaluation and management of a patient, 
which requires the following 3 components: a detailed history; a detailed examination; and medical decision 
making of moderate complexity (code 99284). You say that the billed code 99284 is medically necessary. The 
Plan denied your request. The Plan says the billed code 99284 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 99284. The definition of CPT code 99284 is an emergency department visit 
for the evaluation and management of a patient, which requires the following 3 components: a detailed history; 
a detailed examination; and medical decision making of moderate complexity. 
 
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 an emergency department visit for the 
evaluation and management of a patient, which requires the following 3 components: a detailed history; a 
detailed examination; and medical decision making of moderate complexity (code 99284). Our reviewer says 
that an emergency department visit used for the evaluation and management of a patient, which requires the 
following 3 components: a detailed history; a detailed examination; and medical decision making of moderate 
complexity (CPT 99284) is not medically necessary. Our reviewer found that the enrollee with a history of 
hypertension (HTN) who presented to the emergency department (ED) on September 25, 2022, with right 
wrist/arm pan after a fall 2 months prior. The enrollee was evaluated with a history and physical exam and  
x-rays. The enrollee related a history of no blood pressures medications x 2 weeks. Her blood pressure was 
226/100. The enrollee was treated with Carvedilol, Ketorolac and Percocet. X-rays were negative for fracture. 
The enrollee was given splints and discharged. The review has determined that code 99283 is 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 an emergency department visit for the evaluation and management of a patient, 
which requires the following 3 components: a detailed history; a detailed examination; and medical decision 
making of moderate complexity (code 99284) 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 
the following 3 components: a detailed history; a detailed examination; and medical decision making of 
moderate complexity (code 99284) provided on September 25, 2022.