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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided for emergency services that he did not receive.  Findings:  The physician found that the enrollee has a history of prior nasal surgical interventions. In a previous year, the patient underwent open rhinoplasty and septoplasty along with bilateral inferior turbinate partial resection for symptoms of nasal blockage obstruction and a desire to have improved appearance of the external nose. The patient presented with reports of sinus pressure and recurrent infections. Computed tomography (CT) scan of the sinuses showed evidence of opacification of the right maxillary sinus however there is no evidence of any inflammatory or infective changes of the ethmoid or frontal sinuses. The patient was assessed with nasal congestion and silent sinus syndrome and recommended for revision nasal and sinus surgery. The patient underwent combined intranasal secondary nasal septal reconstruction, inferior turbinate outfracture, right maxillary endoscopic sinus surgical intervention with image guidance, revision external nasal reconstruction with nasal vestibular reconstruction and placement of cartilaginous struts. The patient has requested reimbursement for medical services provided.At issue in this case is whether the enrollee 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. The medical services provided were not necessary for treatment of an emergency medical condition. There was no emergent medical condition noted in the records submitted for review. The patient underwent endoscopic maxillary sinus surgery for chronic polypoid changes obstructing the maxillary sinus outflow tract. Additionally, a functional and cosmetic nasal procedure was performed with revision external rhinoplasty for improvement of the nose following the prior surgery. The patient presented with nasal obstruction and right maxillary sinus issues. Silent sinus syndrome is not an acute issue and does not need emergent management. Based on the clinical documentation submitted for review, the services providedwere not emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that 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 otolaryngology 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.