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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for services on the basis that the services were necessary for treatment of an emergency medical condition. The records show that the patient has a history of limbic encephalitis, muscle weakness, cognitive dysfunction, and was manifesting obsessive-compulsive disorder behaviors. The patient was brought to the emergency room on several occasions. The patient was admitted with four-point restraints due to severe aggressive outbursts, behavioral changes, altered level of consciousness, amnesia, schizophrenia, tic disorder, and a low suspicion of pediatric acute-onset neuropsychiatric syndrome (PANS). Seeking a second opinion, the patient and his family consulted several providers. The patient had a consult with an immunologist for an evaluation of possible pediatric acute-onset neuropsychiatric syndrome (PANS), pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and autoimmune encephalitis (AE). The patient saw various providers and received various services including office visits, lab work and imaging tests (FDG/PET scan and MRI).At issue in this case is whether the patient received emergency medical services on the dates 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 person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. Review of the submitted documentation reveals that diagnoses of Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS), Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) and autoimmune encephalitis were considered in this case. PANDAS has been described as the acute onset of obsessive-compulsive disorder and/or motor tics in children following recent streptococcal infection. More recently, the condition has been renamed Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). Symptoms frequently relapse and remit, and may respond poorly to psychotropic medications. Autoimmune encephalitis is an increasingly recognized etiology for neuropsychiatric deficits that are highly responsive to immunotherapy. In this patients case, the medical services provided do not fulfill criteria for emergency medical services. Although the patient had exhibited abnormal behaviors such as tics, aggression and confusion at times, these were symptoms that had been waxing and waning for several months and were not acute in nature or life threatening per the medical notes provided. There is no documentation that the patient was a physical threat to self or to those around them so as to warrant an involuntary hold or immediate medical attention. The medical services provided were outpatient visits with specialists for second opinions regarding the patients diagnosis. Therefore, the services provided are not considered emergency medical services.Final Result: The reviewer determined the patient did not receive emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child neurology 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.