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 provided.  Findings:  The physician reviewer found that the patient is a 53-year-old female who presented to the emergency department with a seizure that had resolved. The patient was visiting her son in the hospital when she began to feel diaphoretic and lightheaded. A nurse witnessed the patient have a convulsion and subsequently lose consciousness for 45 seconds. The patient denied head trauma, chest pain, or sensory or motor changes. Her past medical history included hypertension. Differential diagnoses included seizure, vasovagal, orthostasis, and anemia. Her vital signs were normal. The patient was fully oriented. No cranial nerve deficits were noted and muscle tone was normal. An electrocardiogram (EKG) showed a sinus rhythm with occasional premature complexes and a prolonged QT interval. A computed tomography (CT) scan of the head was negative for any acute findings. Laboratory data was significant for a troponin of less than 0.01 and was otherwise unremarkable. The patient received intravenous fluids for hydration. The patient was assessed with syncope, unspecified and 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 date 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 was a visitor at the hospital when she sustained loss of consciousness and convulsive activity witnessed by a medical professional. The differential diagnoses included seizure or syncopal convulsions. An EKG, telemetry monitoring and laboratory testing were necessary to assess for cardiac syncope due to arrhythmia or critical aortic stenosis. A head CT was also necessary to rule out an acute intracranial process that could present as new onset seizures. The services provided meet criteria for emergency medical services provided. Final Result: The reviewer determined that the patient received emergency medical services on the date 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.