Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Influenza
Treatment:  Outpatient Facility Service(s): Emergency Room Visit
The insurer denied the Outpatient Facility Service(s): Emergency Room Visit.
The determination is overturned.


The patient presented to the Urgent Care with the complaint of a productive cough, nasal congestion, chills, headache, and body aches since that morning. He was seen by the physician's assistant (PA), who recorded that the patient vomited once after eating breakfast but had since been able to tolerate fluid and foods. He denied taking anything for symptom relief. He reported no previous medical history or allergies. He was afebrile, but mildly tachycardic and hypertensive at 115 beats per minute and 149/78, respectively. His respiratory rate and pulse oximetry readings were normal. He was reported to be ill-appearing on physical exam, but otherwise in no distress, with a normal head, eyes, ears, neck, throat (HEENT), cardiovascular, respiratory, and skin exam. A rapid influenza swab was performed and positive. He was prescribed Tamiflu and discharged home with instructions for symptom control and to follow up with a primary care provider if symptoms did not resolve within 5 to 7 days. At issue is the medical necessity of Outpatient Facility Services: Emergency Room Visit.
The requested health services and treatment by this patient at the Urgent Care were medically necessary. The patient presented with chills, headache, vomiting, and productive cough of one day. He was reported to be ill-appearing on exam, as well as tachycardic upon triage. His influenza swab was positive and he was started on Tamiflu for treatment. Influenza is a highly infectious respiratory illness, responsible for significant time lost from work, morbidity, and mortality. If treatment with Tamiflu is going to be initiated, it must be done within 24 to 48 hours in order to have the most impact on symptom duration reduction and to decrease the risk of serious complications (1). Additionally, this patient was a student away from home, living in a group setting, with the potential to spread influenza to many others. The benefits of treatment with Tamiflu likely outweighed the risks in this setting. This visit to the Urgent Care was medically necessary, as the condition needed to be treated urgently in order to reduce the risk of serious complications and duration of illness.

The patient presented to an urgent care facility, not an emergency department, and therefore does not need to meet the "Prudent Layperson standard" for an Emergency Medical Condition.  He presented with chills, headache, vomiting, and productive cough of one day.  He was reported to be ill-appearing on exam, as well as tachycardic upon triage.  His influenza swab was positive and he was started on Tamiflu for treatment.  Influenza is a highly infectious respiratory illness, responsible for significant time lost from work, morbidity, and mortality.  If treatment with Tamiflu is going to be initiated, it must be done within 24 to 48 hours in order to have the most impact on symptom duration reduction and to decrease the risk of serious complications (1). Influenza falls in to the category of an "urgent" medical condition because treatment needs to be started early on in the illness in order to be helpful, and insureds are routinely directed to urgent care facilities for these types of symptoms.  Additionally, this patient was a student away from home, living in a group setting, with the potential to spread influenza to many others. The benefits of treatment with Tamiflu likely outweighed the risks in this setting. The patient appropriately presented to an urgent care facility. This visit to the Urgent Care was medically necessary, as the condition needed to be treated urgently in order to reduce the risk of serious complications and duration of illness.