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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical services provided for emergency medical services. Findings:  The physician reviewer found that the patient is a female who had a fall while in a restaurant in Amsterdam. She had lost consciousness, had injury to her head and face and was taken to the emergency room and had a magnetic resonance imaging (MRI) performed. She was released from the hospital the next day and cleared for flight back to the U.S. She presented with a laceration that had not been closed. Per the operative report, the preoperative diagnosis was full thickness forehead laceration and the procedure was full thickness forehead laceration repair. The operative report is consistent with an unrepaired 2.5 cm full thickness forehead laceration.  There was no evidence of infection or foreign body. The wound was cultured and sent to pathology. The laceration was then repaired and she was treated with antibiotics. She later presented with a large hematoma following her previous repair and the procedure was to explore and evacuate the hematoma. The operative note is consistent with hematoma evacuation and the central wound was left open to drain and heal by primary intention. Photographs submitted for review show that the patient had injury to the left periorbital and lower forehead areas. The patient has requested reimbursement for medical services provided. Final Result: The reviewer determined that that the enrollee received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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.  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 on 4/29/15 were not necessary for treatment of an emergency medical condition. On 4/29/15, the patient presented with an open wound that had not been repaired. She underwent delayed primary closure. There was no evidence of infection at that time. The indication was that the patient desired full thickness laceration repair. There was no evidence of exposed bone, tendon, or other vital structure that would require emergency services. The provider did not document concern for emergency repair. Therefore, delayed primary closure should not be considered an emergency service, as the exact timing of this closure is not critical, as the time for primary repair had elapsed.  Thus, the patient did not receive emergency medical services on 4/29/15. In regards to 5/1/15, the patient presented with a large hematoma that required immediate attention. An expanding hematoma or possibly an infected wound or infected hematoma should be treated on an emergent basis to avert further complication. Therefore, the patient received emergency medical services on 5/1/15.