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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgical services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention. 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 any of the following: (1) Placing the patients health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. Review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition. Based on the records provided the patients presentation was not consistent with the above definition of an emergency medical condition. She presented with acute arm pain and did not undergo immediate surgical intervention but rather surgery was delayed until her blood pressure came down. There is no indication that the patients arm pain suddenly worsened. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided did not meet prudent layperson criteria for emergency care. However, it has been established that criteria for urgently needed services were met on the date in dispute. The patient presented with acute carpal tunnel syndrome. Acute carpal tunnel syndrome requires urgent surgical intervention to avoid serious sequelae. Acute carpal tunnel syndrome, which is much less common, is more often directly related to fractures and fracture-dislocations about the wrist, hemorrhagic conditions, and vascular disorders involving the wrist. Many rare and unusual causes have been described, including chronic conditions that may be associated with acute carpal tunnel syndrome, such as rheumatologic disorders and anomalous anatomy.  In the setting of acute carpal tunnel syndrome prompt opening of the carpal tunnel is the recommended method of treatment to avoid permanent changes within the median nerve. Due to the patients comorbidity of hypertension she was unable safely return home. The patient, who is of an advanced age, was advised to monitor her blood pressure daily prior to surgical intervention. Based on the documentation submitted for review a prudent layperson in a similar situation would have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient met prudent layperson criteria for urgently needed services. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for urgently needed services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in orthopedic 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.