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

Nature of Statutory Criteria/Case Summary: An enrollee has requested dental services for 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 have sought immediate medical attention on the dates in question. Upon review of the submitted medical records, the patient underwent a dental evaluation two days after he injured his tooth. At the time of evaluation the patient reported some pain and a lot of sensitivity of tooth number 14. Photographs provided show tooth number 14 to have the distolingual cusp fractured off, an existing amalgam restoration in place with a crack across the occlusal surface, breakdown at the margins of the restoration, and possible previous loss of the mesial portion of the restoration. The mesial portion shows signs of recurrent decay which would indicate long-standing decay. The fractured cusp appears to be a recent occurrence as the surface appears not to show any effects of long-term oral exposure. This type of fracture is common in a patient with a longstanding amalgam restoration; a condition evidenced by the decay, fracture, and compromised restoration margins. 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.Further, it has not been established that criteria for urgently needed services were met on the dates in dispute. In this case, the patient presented with a fractured tooth due to an injury. The patient was documented to have some pain and reported no pain. The patient was treated with radiographs, a crown on tooth number 14 and a comprehensive oral evaluation. Based on the patients presenting complaints and symptoms, he 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. In sum, based on the patients clinical presentation on the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.