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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.   Findings:  The physician reviewer found that the patient presented to the emergency department. He reported three days of crampy abdominal pain with repeated vomiting. He denied fever, diarrhea, or dysuria. The patient admitted to recent binge alcohol drinking. His past medical history included cyclic vomiting syndrome, Helicobacter pylori, as well as cannabis use. He had a past history of endoscopy and colonoscopy procedures. His vital signs revealed a pulse of 104, blood pressure of 119/63, respirations of 16, and a temperature of 97.8. The patient appeared mildly distressed. His abdomen was soft without tenderness, rebound, or guarding. Laboratory data was significant for a BUN of 42 and creatinine of 5.34 with a white blood cell count of 22,700, creatine phosphokinase (CPK) of 228, glucose of 175, carbon dioxide of 19, and sodium of 129. The patient was medicated with intravenous Protonix, Phenergan, Dialudid, and two liters of intravenous saline. Repeat vital signs revealed a pulse of 112 and blood pressure of 121/82. The patient was admitted for acute renal failure, dehydration, and cannabis hyperemesis. His symptoms gradually improved. The patient was able to tolerate oral intake. He was discharged. The patient has requested reimbursement for emergency medical services provided.At issue in this case is whether the enrollee received emergency medical services on the dates of service in question. California law defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that persons license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. The services at issue were necessary for treatment of an emergency medical condition. In this case, the patient presented to the emergency department tachycardic after several days of vomiting. His laboratory data revealed acute renal failure with a creatinine of 5.34. After antiemetic treatment and intravenous fluid, the patients tachycardia was more pronounced at 112. The patient required hospital admission in order to stabilize his vital signs. In addition, further intravenous therapy and close monitoring of renal function and electrolytes to prevent permanent kidney damage was indicated. The patient was stable for discharge when he was able to tolerate oral intake and his renal function showed significant improvement. Thus, the services provided were emergency services. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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.