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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.  Findings:  The physician reviewer found that the patient presented with complaints of dizziness, tremors, nausea, shortness of breath and vomiting. She reported five episodes of emesis. Her symptoms began that morning and progressed to the point where she was feeling unsteady on her feet and shaky. The patient reported her dizziness made ambulation difficult. She denied chest pain, headache or fevers. She denied vertigo or hearing loss. Her past medical history included diabetes. The patients initial vital signs revealed a pulse of 90, respirations of 20, blood pressure of 161/90, and an oxygen saturation of 99% on room air. The patient appeared tremulous. Heart sounds were regular without murmurs. Respirations were non-labored. Normal motor strength and sensation were noted. No dysmetria or dysdiadochokinesia was present. An electrocardiogram (EKG) did not show ischemia or dysrhythmia. A chest x-ray was negative for acute disease. Computed tomography (CT) scan of the head was unremarkable. Laboratory data included pyuria and a negative troponin. Her symptoms were improved with intravenous (IV) fluids. The patient was assessed with urinary tract infection, dizziness, nausea and vomiting and dehydration. She was discharged and advised to follow up with her primary care provider. The patient has requested reimbursement for emergency medical services provided.  Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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. 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 persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department with dizziness and difficulty with ambulation. The differential diagnoses included cerebellar stroke as well as acute coronary syndrome, central or peripheral vertigo, orthostasis, dehydration, and potential urinary tract infection. After evaluation including an EKG to rule out myocardial ischemia, a head CT to rule out acute intracranial pathology, and laboratory testing, the patient was stable for discharge. Such symptoms meet the criteria for emergency services as defined above. Thus, the services provided from 10/20/16 through 10/21/16 were for emergency services.