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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for medical air transportation for treatment of an emergency medical condition. Findings:  The physician reviewer found that 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. 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 air transportation and post-stabilization care provided were necessary for treatment of an emergency medical condition. A brainstem stroke in a young patient is one of the most critical neurological emergencies and often suggests a vertebral dissection. Brainstem strokes require extremely close monitoring, quick intervention if they progress, and an advanced level of diagnostic and management care. In this case, the patient necessitated angiography while at the tertiary center in order for further determine the extent of his vascular disease and initiate proper therapeutic management. The angiography demonstrated evidence of a vertebral dissection and guided care. Rapid transfer to a tertiary center given the documented facts of this case was necessary. The absence of this care and appropriate transfer would have placed the patient at unnecessary risk for severe disability and potentially death. Moreover, the post-stabilization care received was necessary for treatment of an emergency medical condition. This was an emergent situation.  The patient had a stroke with significant brainstem findings. Post-stabilization care included close clinical monitoring and an angiogram both are necessary for patients with tenuous brainstem strokes. The absence of this care would have placed the patient at risk of death or severe disability. Therefore, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the date of service at issue. Final Result: The reviewers determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in neurology 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.