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

A 65-year-old male enrollee has requested reimbursement for emergency services. Findings:  The physician reviewer found that The patient is a 65-year-old male who sustained an initial fall and broke his neck and sustained right-sided weakness. He was discharged from an acute care hospital three days later and was admitted to a skilled nursing facility (SNF) the following day with a cervical collar in place. On the day of admission to the SNF or the following day the patient reportedly fell to the floor in the bathroom after slipping off the toilet. He reported no loss of consciousness or complaint of new neck pain. He was taken by ambulance from the SNF to the Emergency Department. The transfer orders from the treating provider at the SNF indicated the patient had a diagnosis of closed fracture of cervical region with spinal cord injury and complained of weakness on his right side that was worse than the previous day. The transfer orders further indicated the patient had an unwitnessed fall yesterday. The patients mental status was described as alert, he had no deficits in communication, he was cooperative and oriented times three and denied pain. The Emergency Department medical documentation indicates the patients right great toe was red, swollen, tender and warm to the touch. His pain level was not quantified by the triage nurse or the physician, but the transportation documents noted a pain score of 0 out of 10. There was no new injury to the neck or new neurological findings. The Emergency Department physician noted that the patient stated he had some mild weakness in his right leg that he only noticed when walking and was not able to put as much weight on that leg when walking (which had been the case since the initial injury). X-rays of the patients right foot were negative for fracture and his uric acid level was normal. He was diagnosed with gout and treated with colchicine 0.6mg. He was given a prescription for this medication and discharged to the SNF. The patient has requested reimbursement for the emergency services provided. The Health Plan has denied this request.At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the date in question. 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.Review of the submitted documentation does not demonstrate that the patient was experiencing acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to his health, serious impairment to bodily functions or serious dysfunction. Although the treating providers at the SNF ordered that the patient be transported to the Emergency Department for further evaluation, the submitted clinical information does not demonstrate that the patient was experiencing acute and/or severe symptoms at the time the transfer was ordered. The patient presented to the ED with complaints of foot pain and redness that had been present for 24 hours and was diagnosed as gout. There is no medical record documentation of an injury from the slip off of the toilet. The level of pain was not severe (according to the transport records the patients pain was 0 out of 10), and it is not clear that the slip off the toilet had anything to do with the foot findings or even when the fall occurred. Thus, although the patients treating provider ordered the transfer to the Emergency Department of an outside facility, and while further evaluation of the patients foot condition by an outside facility/provider may have in fact been necessary, the record does not support that the patient was experiencing acute symptoms of sufficient severity on the date in question to constitute an emergency medical condition as defined by California law. In the absence of acute and/or severe signs and symptoms, the patients reliance upon his providers transfer order is not sufficient to meet prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of emergency care to result in serious jeopardy to his or her health.