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

Nature of Statutory Criteria/Case Summary: An enrollee has requested urgent care services. Findings: The physician reviewer found that the request indicating that the services at issue were not required on an emergent basis or urgent basis. At issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on. 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 date in question. Upon review of the submitted medical records, the patients symptoms had begun two days prior. The patients symptoms were not acute in onset. She had persistent burning pain, but no other complaints. Her eye exam was normal. There were no corneal abrasion or visible burn noted. While the patients symptoms may have warranted a medical evaluation, an evaluation on an emergent basis was not indicated. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she 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 date in dispute. In this case, the patient presented with mild burning pain due to hot oil splashed to her eye two days prior. The patients symptoms were not acute in onset. She was reported to be in no pain with a pain rating of 0/10. She had two days to seek care from her primary care provider or an in-network urgent care. The patients symptoms do not support that the services at issue were necessary to prevent a serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of an existing condition, for which treatment cannot be delayed until the patient returns to the Health Plans service area. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services.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.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.