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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested coverage of urgent care services.  Findings: The physician reviewer found that though the initial services at issue were not required on an emergent or urgent basis, taking into context the patients underlying health condition supports that a prudent layperson in this circumstance would reasonably believe urgent care services were necessary to prevent serious deterioration of the his health.  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. Upon review of the submitted medical records, the patient presented with symptoms of fever, productive cough, shortness of breath, sore throat and chest congestion that had begun four days prior. The patient was alert and cooperative with a calm and appropriate affect. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was 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 did not meet prudent layperson criteria for emergency care. However, it has been established that upon further review criteria for urgently needed services were met. The patient presented with progressively worsening chest congestion associated with fever and sore throat. In addition, the patient had a significant history of coronary artery disease status post stent placement. In this clinical setting, chest congestion could be indicative of congestive heart failure, pneumonia, and other cardiopulmonary disorders, for which treatment cannot be delayed until the patient returns to the Health Plans service area. Thus, the patients symptoms support that a prudent layperson in this circumstance would reasonably believe urgent care services were necessary to prevent serious deterioration of the his health resulting from a complication of an existing condition for which treatment cannot be delayed. 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 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.