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

Nature of Statutory Criteria/Case Summary: This patient had a diagnosis of crushing injury of the right little finger. The patient presented to an urgent care center on 7/10/18. The urgent care records document a right fifth digit crush injury eight days prior. The patient had complaints of pain at the distal interphalangeal joint at an intensity of four of 10, with associated swelling. She reported that the symptoms were better with over-the-counter medications, elevation, and ice packs. The patient reported that her finger appeared broken and that she went to urgent care for treatment of an urgent medical situation. Examination of the right fifth finger documented normal range of motion, no erythema, no laceration, tenderness to palpation over the distal interphalangeal joint, and swelling. X-rays were obtained. The treatment plan recommended rest, ice, compression and elevation. A static finger splint was applied. The patient was planned for follow-up with her primary care provider to review the x-ray results. On 7/13/18, the urgent care center called the patient and informed her that the x-ray was normal. Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Emergency Medical Condition is defined in the Health and Safety Code section 1317.1(b)(b) 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 joint. California Health and Safety Code section 1317.1 (a)(1) defines an emergency services and care as a 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. A review of records did not support that the services that were provided on 7/10/18 were emergency medical services as defined by California law. In this case, the patient presented to an urgent care center with pain in the right fifth finger eight days after the injury. Physical examination of the right fifth finger revealed swelling, normal range of motion, no erythema or laceration, and tenderness to palpation over the distal interphalangeal joint. There was no evidence of acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to resultin any of the following; placing the patients health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or joint. 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 orthopedic surgery 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.