Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A 49-year-old female has requested coverage for past emergency surgical services on four separate dates.  Findings:  The physician reviewer found that the patient has a history of cystic fibrosis and invasive fungal infection of the lung resulting in hemoptysis. She underwent surgery to remove the infected tissue; however, several months later she re-presented with recurrent symptoms and required full pneumonectomy to remove the entire lung on the right side. This left a dead space, and she again presented with cough and brownish sputum. Workup showed erosion of the bronchial stump with empyema and chronic infection with aspiration of fungal material into the opposite lung. Attempts to use biologic glue failed. The patient had right video thoracoscopy in to evacuate the infected space and place a tracheal stent to cover the opening. The patient underwent open thoracotomy with closure of the bronchopleural fistula, placement of a dermal matrix allograft, right serratus anterior and latissimus dorsi muscle flap reconstruction of the right thoracic cavity. She underwent resection of rib, takedown of eloesser flap, and serratus/latissimus muscle flaps, closure of bronchopleural fistula with AlloDerm and serratus flap, and closure of the eloesser flap with latissimus muscle. There was a continued air leak and the patient underwent video thoracoscopy and debridement of the empyema cavity and redrainage of the bronchopleural fistula, with biologic glue placed by bronchoscopy. This again left an air leak and the patient underwent another surgery with omental flap placement for reconstruction repair of the bronchopleural fistula. Plastic surgery and thoracic surgery were intimately involved in all of these procedures. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the dates at issue. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.Review of the submitted documentation demonstrates that the patient was experiencing complications of a complex medical condition during the summer/fall of last year. The patients medical issues were chronic in nature and a series of complex procedures were required to treat her condition. While the procedures described above were appropriate and necessary, there is nothing about the patients condition on the dates of service at issue that would cause a prudent layperson to believe that immediate medical attention was required. The patient was experiencing a bronchopleural fistula (air leak) on the dates of service at issue; this was a chronic condition which the patient had been experiencing over the course of several months since her initial presentation. It is not likely that a prudent layperson would believe that immediate medical attention was required to treat this condition. The patient did not present to the emergency department for treatment on the disputed dates but rather underwent a series of scheduled procedures over the course of several months. All told, the patients symptoms on the dates at issue did not meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of immediate care to jeopardize his or her health.