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

Nature of Statutory Criteria/Case Summary: An enrollee has requested medical services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson in the patients circumstances would have sought immediate medical attention on the dates of service in dispute. 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 dates in question. Upon review of the submitted medical records, the patient presented with previously diagnosed Fibromuscular Dysplasia (FMD). The documentation for the dates of service at issue do not indicate that the patient was having any acute or abrupt change in her chronic condition. The patients daily headaches were noted as chronic and ongoing over the last year. The neurologic exam was within normal limits and the patient did not have any new or worsening neurologic symptoms or pain. The occipital nerve injection was indicated for chronic daily headaches with tenderness to palpation in the sub occipital area. In this case, the patient appeared stable and without any new or worsening symptoms. 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 provided on the dates of service at issue 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 dates in dispute. In this case, the patient presented with a history of FMD diagnosed. The documentation from the treating facility does not indicate that the patient was having any acute or abrupt change in her chronic condition. The patient did not have any new or worsening neurologic symptoms or pain. The occipital nerve injection was indicated for chronic daily headaches with tenderness to palpation in the sub occipital area. In this case the beneficiary appeared stable and without any new or worsening symptoms. The exam was without focal neurological abnormalities. Recent imaging had shown that the patients condition was stable. Based on the patients presenting complaints and symptoms, the services at issue were not necessary to prevent serious deterioration of the patients health resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the patient returns to the Health Plans service area. In sum, based on the patients clinical presentation on the dates of service in dispute did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.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 internal 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.