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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services that were provided on 12/17/16 to 12/23/16. An undated invoice states that the enrollee was in the hospital from 12/9/16 through 12/16/16 and 12/17/16 through 12/23/16. According to the patients IMR application dated 2/19/19, she was traveling in Vietnam and required emergency surgery to alleviate kidney stones. Detailed medical information is not available for review. There is a translation of documents called a List of Examination and Treatment Charges for admission from 12/9/16 to 12/16/16, which states that emergency admission was for kidney stones. There is documentation about surgery, intensive care unit (ICU) care services, and ultrasound. The details suggest dressing changes to a surgical incision, placement of a JJ-type catheter in the ureter, removal of gallstones through the skin, laparoscopy and endoscope to measure gallstones. There is a second document called a List of Examination and Treatment Charges for admission from 12/17/16 to 12/23/16 that states admission for obstructive and reflux nephropathy due to gall-stones and ureter. There are also charges for removing gallstones through the skin, removal of kidney and urethral catheter a computerized tomography (CT) and abdominal ultrasound, digitalized x-ray and echocardiogram, an endoscopy of the bladder and ureter, placement of JJ catheter in the ureter, removal of urethral catheter, as well as for intravenous fluids, and use of hospital bed. At issue is whether the services provided from 12/17/16 to 12/23/16 were emergency services.Per Health and Safety Code section 1317.1, emergency medical services are services needed to treat or diagnose an emergency medical condition. Per that same provision, an emergency medical condition is 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 placing the patients health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part.The current medical documentation is largely lacking the details regarding the type of services provided during this admission. The majority of patients who present with renal colic from obstructing stones can be discharged within 24 to 48 hours of presentation. There is no documentation provided for review to establish that the patient had a medical condition that placed the patients health in serious jeopardy, or was likely to cause serious impairment to bodily function or serious dysfunction of any bodily organ or part. Therefore, the services provided from 12/17/16 to 12/23/16 were not emergency services.Final Result: The reviewer determined that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in urology 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.