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 complexity (CPT 99285) provided on November 12, 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 complexity (CPT 99285). 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 billing and payment rules. Medicare rules say that providers must report services 
correctly. Providers must report services with the appropriate CPT code. 
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 
In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 complexity (CPT 99285) Our reviewer says 
that the services at issue in this case were not supported by the medical records. Our reviewer found that  
CPT 99284 was more appropriate in this case. There was no decision making of high complexity and 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 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 complexity (CPT 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: a comprehensive history; a comprehensive examination; and medical decision making of high 
complexity (CPT 99285) provided on November 12, 2022.