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

A 21-year-old male has requested approval for past services provided on an urgent basis for treatment of his foot fracture.   Findings:  The physician reviewer found that the patient sustained fractures of the right foot while outside of the Plans service area. The patient was involved in a motor vehicle accident and was seen in an emergency room where x-rays were obtained. He was told that he had suffered a contusion, and was discharged. Because of pain with ambulation, the patient returned to the emergency room eight days later and a CT scan was obtained. The patient was then placed in a splint and on crutches. For a few days, he had increasing calf pain. On examination, there was tenderness, no swelling, and intact neurovascular functions. The x-rays of the right foot on the original visit were described as showing non-displaced fractures of the base of the 2nd, 3rd, and 4th metatarsals. The CT scan of the right foot dated eight days later was described as showing these fractures, as well as a fracture of the cuboid. The patient was placed in a non-weight bearing short leg cast, and medications were prescribed.The patient returned for follow-up on two separate occasions the following month. The provider noted that the patient still had some calf pain and tenderness. An x-ray was obtained and described as showing healing of the fractures. The patient was placed in a short-leg walking cast. Flexeril was prescribed for the muscle tightness. The next month, the patient returned, and noted some pain on weight bearing in the cast. X-rays were performed and described as showing healing of the fractures and the patient was placed in a cam-boot, weight bearing as tolerated. The patient returned toward the end of the month, reporting that he had caught his foot on a stair, with increased pain. The provider indicated that on examination there was tenderness, but no neurovascular loss. An x-ray was described as showing increased healing of the fractures, and the patient was advised to continue the present course of treatment. He returned again the following month, indicating that he was on his feet thirteen hours daily, and had increased pain. On examination, there was some tenderness and a trace of effusion in the midfoot. An x-ray was described as showing healing of the fractures. Continued weight bearing in the cam-boot was suggested. At issue in this case is whether a prudent layperson would have sought treatment on an urgent basis during the three-month period at issue. `Urgently needed services` are those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the Plan's service area.Fractures of the lesser metatarsals, single or multiple, undisplaced or minimally displaced, are usually treated symptomatically. In the case of this patient, there is a lack of documentation to indicate that the services provided from the second month onward met criteria as urgently needed services. The patients fractures were undisplaced. By this time, the fractures had been identified by CT scan and the patient had been placed in a cast. There was no indication for surgical or other more aggressive treatment, and a problem with healing was not evident. There is a lack of documentation to indicate that there was any displacement of the fractures or delay in healing. As such, there is no evidence that would cause a reasonable person to believe that further treatment could not be delayed until the patient returned to the Plan's service area.