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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospital inpatient services. California Health and Safety Code  1317.1, subdivision (a)(1), 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. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part.In this case, the patient received emergency services from their arrival in the emergency room and for the following three days in inpatient status. On presentation to the ER and shortly afterwards, the patient had sepsis, as assessed by their Quick Score for Sepsis (qSOFA) score. In addition, the patient was also febrile, tachycardic and had an elevated procalcitonin level. The patient had a known source of infection with a resistance strain of E. Coli. Furthermore, the patient had failed many outpatient treatment attempts at treatment. Sepsis has a high mortality rate and thus must be diagnosed quickly so treatment can be started to prevent unnecessary morbidity and mortality. In sum, the patient presented in time to obtain evaluation and treatment, thus recovering from the sepsis (not necessarily the infection) quickly. Under these circumstances, the patient was being treated for an emergency medical condition that placed their health in serious jeopardy from their arrival in the emergency room and for the following three days in inpatient status, and the services provided were emergency medical services as defined by California law.Regarding services provided from the patients fourth day as an inpatient until discharge, however, the submitted documentation does not reflect that the patients health was in the same jeopardy as during the preceding days. While the patient did require consultations with the various specialties and needed to make decisions about long term vascular access and arrangement for home therapy during this period, these activities were not necessary to relieve or eliminate an emergency medical condition. Accordingly, the services provided from the patients fourth day as an inpatient until discharge were not emergency medical services as defined by California law.Final Result: The reviewer determined that a portion of the services at issue were emergency medical services. Specifically, the reviewer determined that the services provided from the patients arrival in the emergency room and for the following three days in inpatient status were emergency medical services, and that the services provided from the patients fourth day as an inpatient until discharge were not emergency medical services. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine 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.