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

Nature of Statutory Criteria/Case Summary: The parent of the enrollee has requested reimbursement for services provided. The Health Plan has denied this request indicating the enrollee did not receive emergency medical services.The patient is a female with persistent genital arousal disorder (PGAD) and a question of contributing balanitis without acute evidence of inflammation or drainage. Records show a dorsal slit procedure was performed. The Health Plan has denied reimbursement for services provided. Per the Health Plan, the patient did not receive emergency medical services. This denial is the subject of this appeal and determination.Per medical criteria, emergency services and care means 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 person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. Under California law, emergency services are defined as services provided to diagnose or treat an emergency medical condition. 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 placing the patients health in serious jeopardy, serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part.In the absence of acute purulent drainage consistent with underlying balanitis or evidence of cellulitic involvement of the clitoral hood, there is no support for emergent dorsal slit of the clitoral hood to expose the underlying glans clitoris. Per the records, examination of the external appearance of the clitoris gave no indication of an acute process or a potential organ or life threatening disorder requiring urgent intervention. The patients condition was by history chronic in nature, without clinical deterioration. The records do not document acute symptoms of sufficient severity 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 and/or serious dysfunction of any bodily organ or part. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical 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 with sub-specialty certification in pediatric 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.