Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency department services (99285) provided to the 
enrollee on December 5, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this emergency department visit (99285) was not appropriate for this patient based on the reason 
for visit, diagnostic work-up, and patient complexity. 
 
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 the relevant codes in this case are: 
 
CPT 99284: 
 
Emergency department visit for the evaluation and management of a patient, which requires these 3 key 
components: A detailed history; A detailed examination; and Medical decision making of moderate 
complexity. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the 
physician, or other qualified health care professionals but do not pose an immediate significant threat to life or 
physiologic function 
 
CPT 99285: 
 
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. Counseling and/or coordination of care with other physicians, other qualified health care 
professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or 
family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat 
to life or physiologic function 
 
We asked our coder 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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the review has determined that based 
on the submitted documentation, the emergency department visit (CPT code 99285) was not appropriate for 
this patient based on the reason for visit, diagnostic workup, and patient complexity.The submitted visit level of 
CPT code 99285 was not appropriate in this case. The patient presented with a moderately complex problem of 
a possible gastrointestinal (GI) bleed. She was hemodynamically stable with a normal hemoglobin. This was 
not an immediate threat to life or physiological function that is typical of a CPT code 99285 visit. The review 
has determined that the plan was justified to downgrade to 99284. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for emergency department services (99285) provided to the enrollee on December 5, 2021.