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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services provided at Bumrungrad International Hospital in Thailand. Zaina and colleagues describe lumbar spinal stenosis as a debilitating condition associated with degeneration of the spine with aging. The authors report that no clear benefits were observed with surgery versus non-surgical treatment, and that while the rate of side effects ranged from 10% to 24% in surgical cases, no side effects were reported for conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. Lurie and Tomkins-Lane note that given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is usually elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. In this case, the records do not reflect that the patient was experiencing rapidly worsening neurological deficits. The submitted documentation does not demonstrate that treatment could not be delayed until the patient returned to the plans service area. Additionally, the records do not establish that the absence of immediate medical attention would result in the patients health being in serious jeopardy or serious impairment to bodily functions. Therefore, the services provided at Bumrungrad International Hospital in Thailand were not (1) emergency medical services, defined 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, 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; or (3) serious dysfunction of any bodily organ or part 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; and were not (2) urgent care services, defined as services to prevent serious deterioration of the enrollees health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the enrollee returns to the plans service area.Final Result: The reviewer determined that the services at issue were not emergency medical care, as defined in Health and Safety Code section 1317.1, and were not urgent care services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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.