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 provided on June 30, 2022. 
 
You asked the Plan to pay for the emergency department visit. The Plan denied your request. The Plan says the 
level of care that was provided was felt to meet criteria for code 99284 (Level 4 visit) and was paid 
accordingly. 
 
The Plan must follow 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. 
 
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 
(code 99285). Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found that the review indicates that you presented to the emergency department (ED) on 
June 30, 2022 with complaints of flank pain for the past 2.5 weeks. You were seen at a different ED on  
June 13, 2022 for these symptoms. You were noted to have right-sided flank pain at the time of the previous 
visit of June 13, 2022. You were treated with Bactrim for a urinary tract infection and finished the cycle of 
medication. You were also prescribed Norco and Zofran, which you reported having been taking. The records 
note that you reported having continued left-sided flank pain rated 10/10 on visual analogue scale that shoots 
down your leg. Subsequent documentation in the submitted records notes that you have right-sided flank pain. 
Physical exam documents the presence of right lower back tenderness and right posterior pelvic tenderness/hip 
tenderness. You were described as having no generalized weakness and noted to be otherwise without 
symptoms from hyponatremia. You were treated with intravenous fluids and repeat sodium was 125. This was 
thought to be likely related increased free water intake with decreased solute intake. Your back pain was felt to 
be musculoskeletal or sciatica with plan to treat symptomatically. The notes document that the case was 
discussed with nephrology. Nephrology was noted to agree with the ED physician's assessment and plan. 
Nephology recommended one gram sodium chloride tablets twice daily for one week and then repeat labs. The 
ED physician's clinical impression was documented as: 1. Back pain, unspecified back location, unspecified 
back pain laterality, unspecified chronicity. 2. Hyponatremia. In this case, the documentation indicates that you 
were thought to have back pain, likely musculoskeletal in nature, and hyponatremia without symptoms. The 
number of diagnoses or management options for this episode of care appear to have been limited. The records 
do not show that your presenting problem(s) were of high severity and posed an immediate significant threat to 
life or physiologic function. In addition, the medical decision making as documented would not be considered 
to be of high complexity. The review has determined that code 99284 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 the physicians review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the emergency department visit (code 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 provided on June 30, 2022.