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 level of high complexity (CPT 99285) provided on  
August 24, 2022. 
 
 
 You asked the Plan 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 level of high complexity (CPT 99285) provided on August 24, 2022. You say that the correct 
CPT code 99285 was billed. The Plan denied your request. The Plan says CPT code 99285 is not supported by 
the medical records. 
 
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. Providers 
must report services with the appropriate CPT code. 
 
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 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 level of high complexity (CPT 99285). 
Our reviewer says that the services at issue in this case were not supported by the medical records. Our 
physician reviewer found that the enrollee was a then, 60-year-old with a history of congestive heart failure 
(CHF), panic, and anxiety who presented to the emergency department (ED) on August 24, 2022 with back 
pain 5 days status post L5-S1 fusion. The enrollee had started Lasix due to bilateral leg swelling. The enrollee 
was evaluated and there was no laboratory or chest X-ray evidence of CHF. The enrollee had analgesics at 
home and was discharged the same day with primary care physician follow-up. The review has determined that 
CPT 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 this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage 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 level of high complexity (CPT 99285) provided on August 24, 2022 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 level of high complexity (CPT 99285) provided on 
August 24, 2022.