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

Nature of Statutory Criteria/Case Summary: A 46-year-old female enrollee has requested reimbursement for emergency services as defined in Health and Safety Code Section 1317.1, subdivision (a)(2)(A). The patient is a 46-year-old female who has been diagnosed with major depressive disorder, unspecified eating disorder, and alcohol use disorder in sustained full remission. She had no reported history of hospitalization prior to the disputed service and there was no known history of suicidal behavior. In addition to pharmacotherapy consisting of citalopram, bupropion, clonazepam, lamotrigine and lithium, the patient had also been treated with outpatient therapy. In the months prior to admission, the patient reported depressive symptoms including low mood, guilt, anxiety, poor focus and decreased energy with a desire to stay in bed all day and an inability to get things accomplished. Although mindful of the self-defeating result, she was overeating as a means of coping. Feeling stressed and unsupported, and upon the urging of friends and family, the patient presented at the treatment facility and was admitted to a month-long residential program. The patient has requested reimbursement for emergency services as defined in Health and Safety Code Section 1317.1, subdivision (a)(2)(A). The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.At issue in this case is whether the enrollee received emergency medical services on the date(s) of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. In general, emergency medical services are indicated in an acute psychiatric syndrome and typically delivered in a specialized acute inpatient unit. Although the level of care in this case was reasonably expected to improve the patients condition and prevent a more serious episode of illness, the patient did not receive emergency medical services during the disputed timeframe. Upon self-presentation, the patient was motivated for treatment. She had good insight and judgment. Her thought processing was clear and coherent. She denied any suicidal ideation or homicidal ideation, and there was no mention of disruptiveness, psychosis, intoxication, withdrawal, agitation or paranoia. In sum, although depressed and anxious, the patient was not experiencing an acute psychiatric syndrome. She did not require and did not receive emergency psychiatric services during the residential treatment stay.The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were not necessary for treatment the patients medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.