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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for services provided. Findings:  The physician reviewer found that The patient has a history of smoking, anxiety and hyperlipidemia. The patient presented to the emergency department on the day of dispute with chest discomfort for a few weeks associated with dyspnea and diaphoresis. The patient was subsequently ruled in for a non-ST-elevation segment elevation myocardial infarction (NSTEMI). The patient was treated with Lovenox and Integrilin. Cardiac catheterization performed  and reported a left ventricular ejection fraction of 20% and a stent was placed to the left anterior descending coronary artery that was described to have a spontaneous dissection and thrombus. A LifeVest was placed and the patient was discharged. The patient is requesting reimbursement for hospitalization services provided from date of dispute through  date of discharge. At issue in this case is whether the enrollee received emergency medical services on the dates 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 person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. A screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service. The hospitalization services provided from dated of dispute through discharge were necessary for treatment of an emergency medical condition. The patient had an unstable coronary syndrome with evidence of acute myocardial infarction and coronary thrombus which constitutes a medical emergency and requires hospital admission by all standards of care. Subsequently, she underwent cardiac catheterization with a reported left ventricular ejection fraction of 20% and placement of a stent to the left anterior descending coronary artery that was described to have a spontaneous dissection and thrombus. The patients medical condition constitutes a medical emergency and immediate medical attention was indicated. For the reasons provided, the services at issue were necessary for treatment of an emergency medical condition. Thus, the patient received emergency medical services on the dates of service at issue. Final Result: The reviewers determined that the patient received emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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.