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 20, 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 CPT 99285 is medically necessary. The Plan denied 
your request. The Plan says 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 CPT 99285 is not medically necessary. Our reviewer found the enrollee was a then 76-year-old with a 
history of hypertension. The enrollee presented to the emergency department (ED) October 20, 2022, with 
complaints of fatigue. The enrollees blood pressure was elevated; the electrocardiogram (EKG) was without 
any acute changes. The enrollee was given Hydrochlorothiazide (HCTZ) and her condition stabilized and 
improved. The enrollee was given a prescription for HCTZ to take in addition to Losartan. The enrollee was 
discharged with instructions to follow-up with her primary care physician. The review has determined that  
CPT 99284 was more appropriate in this case. There was no decision making of high complexity or presenting 
problems 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 (Current Procedural Terminology code (CPT) 99285) provided on October 20, 2022.