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: A detailed history; A detailed examination; 
and medical decision making of moderate complexity CPT 99284) provided on September 19, 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: A detailed history; A detailed examination; and medical decision 
making of moderate complexity (CPT 99284). You say that the billed CPT code 99284 is supported by the 
medical records. The Plan denied your request. The Plan says the 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 (CPT 99284) 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 99284. The definition of CPT code 99284 is 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. 
 
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: A detailed history; A detailed 
examination; and medical decision making of moderate complexity (CPT 99284). Our reviewer says that 
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 
(CPT 99284) is not medically necessary. Our reviewer found that the enrollee was a 66-year-old who presented 
to the emergency department (ED) on September 19, 2022, with a right index finger laceration. The laceration 
was 0.7cm long/depth 1mm. The laceration was cleaned, and tissue adhesive was applied. The enrollee was 
given a prescription for antibiotics and instructions to follow-up with her primary care physician in three days. 
The review has determined that CPT 99283 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: 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 an 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 (CPT 99284) provided on September 19, 2022.