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 June 21, 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 that the enrollee was a then, 69-year-old who 
presented to the emergency department (ED) on June 21, 2022, with gait issues and reported hypotension at her 
primary care physicians (PCP) office. The enrollee was evaluated with a history and physical exam, laboratory 
studies, electrocardiogram (EKG), chest x-ray (CXR) and a computed tomography (CT) scan of the brain. The 
CT was normal; the EKG demonstrated intraventricular conduction delays (IVCD). The CXR demonstrated an 
opacity in the right upper lung. The enrollee remained stable and was discharged home with PCP follow-up. 
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 June 21, 2022.