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

A 39-year-old male enrollee has requested reimbursement for chiropractic services. The Health Plan has denied this request indicating the services at issue were not required on an urgent or emergent basis.  Findings:  The physician reviewer found that the patient was in a parked minivan which was struck by another vehicle. His body was not directly struck by that vehicle, but he did sustain injuries related to the rapid body movements caused by the impact.  He had no focal head injury or loss of consciousness.  He did not seek medical attention on the day of the collision for reasons related to his wifes injuries and the need to care for his children, but he saw a chiropractor the next day with complaints of pain in his head, neck, upper and lower back, pelvis, and left elbow with numbness in his right hand.  His pain was generally in the 7 out of 10 range. Multiple x-rays were obtained which showed degenerative changes but did not identify any fractures or dislocations. The patient was treated with chiropractic manipulation on that day and returned to that office for repeat treatments. The patient is seeking reimbursement for the visits that took place over a 17-day period, as those visits were felt by the patient to be of an urgent/emergent nature.  No medications were prescribed by the chiropractor.  At issue in this case is whether a prudent layperson would have sought immediate medical attention after during the timeframe 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.  Urgently needed services are 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.  In the case of this patient, the nature of the collision, and the severe pain and numbness that the patient was experiencing as a consequence of that collision, would lead a prudent layperson to fear that serious dysfunction of a bodily organ or part may be present and to seek treatment, as this patient did, on the day after the accident. However, the x-rays taken on that day did not substantiate the presence of acute bony injury and the patients symptoms could be attributed to strain, sprain and/or contusion. Ongoing treatment for these conditions would be appropriate, however, a prudent layperson would not expect the services at issue were not considered urgent/emergent in nature and the patient could have sought treatment at that time from an in-network provider.  Although, the services provided on the day after the accident were urgent/emergent in nature, the patients symptoms for the following 17 days did not meet prudent layperson criteria for urgent or emergency care. A prudent layperson in the patients circumstances would not reasonably expect the absence of urgent or emergency care to jeopardize his or her health. Therefore, the Health Plans denial was appropriate and should be upheld.