Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the 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 (CPT 99284) provided from October 12, 2022 to  
October 13, 2022. 
 
You asked the Plan to pay for the 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 (CPT 99284). You say that the code billed is correct based on the medical 
records. The Plan denied your request. The Plan says based on review of the medical records; the billed code 
99284 is not substantiated by the clinical documentation. 
 
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 the emergency department visit  
(CPT 99284). Our reviewer says that the requested emergency department visit (CPT 99284) is not medically 
necessary. Our reviewer found that the enrollee is a 44-year-old with anxiety and depression who presented to 
the emergency department (ED) via ambulance following stressful past few weeks and recent ingestion of 2 
pills of Xanax 0.5 mg and 2 pills of Zoloft 25 mg at the same time which was double her daily prescribed 
dosing for each of these. The enrollee was sent to the hospital by her husband for a suspected suicide attempt 
but after investigation, it was not a suicide attempt and the enrollee was simply trying to treat her anxiety. The 
enrollee was evaluated and was medically stable. The enrollee was seen by a psychiatrist and was also 
psychologically cleared for discharge. The enrollees dosage intake of these medications is not very high, and 
the workup did not reveal evidence of toxicity. Therefore, the CPT 99284 was not supported due to the case 
lacking severe problems or requiring high complexity decision making. CPT 99283 would be more 
appropriate.  
 
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 the following 3 components: a detailed history; a detailed examination and medical decision 
making of moderate complexity (CPT 99284) have not been met. Therefore, we decided that the Plan does not 
have to pay for the 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 (CPT 99284) provided from October 12, 2022 to October 13, 2022.