Appeal type: Medical necessity
Decision: Upheld

Diagnosis: "Enterobiasis (pinworm) 

Treatment: Emergency services

The insurer denied coverage for emergency services. The denial was upheld.

This patient is a female child with a past medical history notable for otitis media, conjunctivitis, and heart murmur that presented to the Emergency Department for evaluation of possible pinworms. The family notes that the child was crying during the night with perianal discomfort/itching and parasites seen at her last bowel movement. She had no other associated symptoms. Specifically she had no fever, vomiting, diarrhea or bleeding. Her last pediatric office visit was for fever 100.5, rash and ear pain. Her vitals were notable for Temperature 36.1 C, Heart Rate 107, Respiratory Rate 30 and oxygen saturation of 97% on room air. She had no pain at presentation. Her physical exam was unremarkable. No imaging or laboratories were obtained. She was prescribed mebendazole and discharged home for outpatient follow-up.

The insurer is denying coverage for the requested services for lack of medical necessity. The patient's presenting symptoms did not appear to represent a clinically emergent situation necessitating the use of the Emergency Department setting.

This patient appears to have had an uncomplicated pinworm infection that presented to the Emergency Department on a Saturday since the pediatrician's office was reportedly closed. In a summary of Enterobiasis infection from UptoDate the authors conclude the following:

"Enterobiasis

The life cycle of Enterobius begins with egg deposition by gravida adult female worms on the perianal folds. Autoinfection occurs by scratching the perianal area and transferring infective eggs to the mouth with contaminated hands. Person-to-person transmission can occur by eating food touched by contaminated hands or by handling contaminated clothes or bed linens.

Most Enterobius infections are asymptomatic. The most common symptom of enterobiasis is perianal itching, which occurs predominantly at night. Occasionally, the worm burden is so high that abdominal pain, nausea, and vomiting develop. Enterobiasis can be diagnosed via examination of cellophane tape for eggs after pressing to the perianal skin. The utility of stool examination is limited since worms and eggs are not generally passed in stool"

According to NYS Insurance Law - Section 4900 describes an emergent condition as a medical or behavoral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in:

1) Placing the afflicted individual in serious jeopardy
2) Serious impairment to bodily functions
3) Serious dysfunction of any part of the individual
4) Serious disfigurement

Given the above factors this patient's medical condition and care needs do not meet standards for medically necessity for Emergency Department care as per NYS policy. Pinworm treatment is never emergent and certainly wasn't in this case. Her described condition at presentation was unremarkable and clearly deemed "non urgent" in triage. Due to the pediatrician's office being closed her family chose to go to the Emergency Department. The covering doctor on call could have prescribed treatment without examining the child or could have directed the parents to over-the-counter treatment or an Urgent Care Center. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for emergency room services is not substantiated.  The insurer's denial is upheld.