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

Nature of Statutory Criteria/Case Summary: An enrolleehas requested reimbursement for medical transportation services provided Findings:  The physician reviewer found that the enrollee who was residing in California when he was involved in an accident with a motor vehicle while riding a bicycle,  The enrollee was transported to a local emergency room then transferred to a trauma center. The enrollee was diagnosed with a traumatic brain injury and underwent craniectomy. The enrollee sustained multiple soft tissue injuries, including abrasion and laceration injuries. The enrollee was transferred to a brain and spinal injury center for further care.  The patient was in a comatose state and had a C2 vertebral body fracture requiring cervical collar and spinal precautions. The patient underwent tracheostomy and gastrostomy tube placement.The patient was tracking and showing some purposeful movements. The provider recommended the patient to undergo a comprehensive rehabilitation program near the patient's support system in another states. The patient was accepted to a university acute inpatient rehabilitation hospital in another state for further care. A ground ambulance trip was reported to be 1,930 miles, a total of 30 hours. The patient was taken by air ambulance from the California hospital to the rehabilitation hospital in another  states without incident. The patient has requested reimbursement for medical transportation services provided. 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 person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.The medical transportation services provided were not necessary for treatment of an emergency medical condition. Traumatic brain injury is a major cause of disability in adults. Recovery can be protracted. Focused, comprehensive rehabilitation for this condition is necessary in appropriate candidates, but does not constitute an emergency. A transfer to a rehabilitation facility out of state so that the patient can be near the enrollee's  support system does not constitute an emergency. In this case, an emergency medical condition did not exist on the date in question. The patient was being transferred from California to another state for continuation of a rehabilitation program in a geographic area closer to the patients support system. This was not an emergency medical condition. Thus, the patient did not receive emergency medical services on the date of service at issue.Final Result: The reviewers determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number two is board certified in physical medicine and rehabilitation 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.