Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for 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 January 20, 2023.  
 You asked the Plan to pay for 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 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) was medically necessary. The Plan 
denied your request. The Plan says the medical record does not support coverage for CPT 99285. 
 
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 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 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 CPT 99285 is not medically necessary. Our reviewer found that the enrollee presented to the emergency 
department on January 20, 2023, with substernal/epigastric pain, headache, nausea. The workup ruled out acute 
coronary syndrome (ACS) and other serious acute conditions. The enrollee was diagnosed with acid reflux, was 
given a proton-pump inhibitors, and sent home. The history was detailed; however, the enrollee was stable and 
did not show signs of a problem of high severity that threatened the enrollees life or physiologic function. The 
documentation for this encounter did not support decision-making of high complexity.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 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 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 January 20, 2023.