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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. Researchers noted that low back pain continues to be a challenging condition to manage effectively. Recent guideline recommendations stress providing non-pharmacological care early, limiting diagnostic testing, and reducing exposure to opioid pain medications. One study concluded that there is strong evidence that lumbar transforaminal injection of steroids is an effective treatment for radicular pain due to disc herniation. This patient presented on several dates for follow-up of low back pain with left leg radiation. Initially, the patient reported painful radiculopathy with reduced function and activities of daily living. The patients range of motion was decreased due to pain and straight leg raise was positive. The records demonstrated pain with decreased function to support the visit as urgent, due to the risk of a further serious deterioration of the patients health within a short period of time. This is further supported by the providers recommendation for an MRI. The treating provider suspected disc herniation, which was worse on imaging than suspected. The next visit was also urgent in nature since the patient had markedly abnormal findings on magnetic resonance imaging (MRI), which revealed an extruded disc with mass effect on the S1 nerve root. The next visit revealed evidence of neurologic progression with documented motor and sensory abnormalities. Thus, the visit was urgent as the patient noted in sensing a further serious deterioration of her health within a short period of time. The visit for evaluation and treatment including lumbar epidural steroid injection was urgent due to the severity of findings. Without such appropriately urgent evaluation and treatment, even further aggressive neurologic determination would likely have occurred. The visit was appropriate due to risk of further serious deterioration of health that could not have reasonably awaited in-network treatment. Finally, the last visit was urgent as the patient prudently perceived the dangerous risk to her health that could not await in-network treatment. The patients neurologic condition had progressed to an antalgic gait, likely due to the mass effect on the S1 nerve root. The condition did not respond to the prior lumbar epidural steroid injection or medications and activity reduction, which supported an urgent visit. This was also due to the danger to further health deterioration. Given these findings, the services were urgent care services defined as services to prevent serious deterioration of the patients health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plans services area.Final Result: The reviewer determined that the services at issue were urgent care services for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The 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.