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 10, 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 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 CPT 99285 at issue in this case is supported by the 
medical records. The Plan denied your request. The Plan says CPT 99285 at issue in this case is not supported 
by the medical records. 
 
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 the 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 at issue in this case is not supported by the medical records. Our reviewer found that the 
enrollee has a history of hypertension (HTN) and was evaluated in the emergency department (ED) on 
November 10, 2022, for abdominal pain, nausea and vomiting for three days. The enrollee was evaluated with a 
history and physical exam, laboratory studies and a computed tomography (CT) scan of the abdomen and 
pelvis. The enrollee was treated with intravenous (IV) fluids and IV Zofran. The CT scan was negative. The 
enrollees condition stabilized and improved, and the enrollee was discharged home. The review has 
determined that CPT 99284 is more appropriate in this case. There was no decision making of high complexity 
and no presenting problems 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 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 10, 2022.