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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.   Findings:  The physician reviewer found that The patient who presented to the emergency department after being notified of a positive blood culture. The patient received a call from the emergency department advising him to go to the hospital immediately. Of note, the patient was seen the day before for fever, generalized weakness and urinary symptoms. He was found to have a urinary tract infection and laboratory testing was performed. He returned to the emergency department for re-revaluation due to blood cultures noted to be growing gram negative rods. The patient reported persistent fever. His abdomen was soft and non-tender. Laboratory data was significant for a white blood cell count.  Intravenous (IV) Rocephin was administered. The patient was noted to likely have some bacteremia related to his urinary tract with no evidence of severe sepsis. He received a liter of IV fluids and possible admission was discussed. He was discharged home in improved condition. The patient has requested reimbursement for emergency medical services.At issue in this case is whether the enrollee received emergency medical services on the date 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. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient was called by an emergency physician and advised to return to the emergency department for a positive blood culture. He had been diagnosed with a urinary tract infection the day prior and started on oral antibiotics. Gram negative rods in a blood culture are considered pathologic and they would not be present from skin contamination. The only explanation for their presence is bacteremia, putting the patient at significant risk for sepsis and septic shock. As such, any patient growing gram negative bacteria in their blood warrants emergent examination and repeat laboratory testing is essential to determine if the patients condition is improving or deteriorating. The standard of care is to recall such patients for evaluation of vital signs and laboratory data, which is necessary to assure the patients condition has been stabilized. Such treatment meets criteria for emergency services. As such, the patient received emergency medical services.  Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency medicine 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.