Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested reimbursement for emergency services. The patient is a 29-year-old female with a medical history significant for Crohns disease who presented to the emergency department with severe abdominal pain. The pain had been present for 1.5 weeks but had worsened over the prior two days. She was treated and discharged earlier the same day in an in-network emergency department. She was reportedly diagnosed with inflammation in her colon and was to follow-up as an outpatient with her provider. Her pain was noted to be 10/10 in severity at the time of presentation. Her emergency department evaluation included a complete blood count, chemistries, urinalysis, pregnancy test, lipase level and review of the computed tomography (CT) scan results from the earlier emergency room visit. The CT report showed moderate ascending colon and cecal wall thickening concerning for infectious versus inflammatory colitis. She was treated with intravenous fluids, intravenous (IV) pain medication and IV anti-emetics. Her pain was improved but persisted and she was admitted for pain control, IV fluids, and a gastroenterology consultation. At the time of admission, the patient reportedly refused transfer to an in-network facility and told the provider she only wanted to be admitted to the out-of-network facility where she was currently being treated in the emergency room. She was admitted from the emergency department to inpatient hospitalization. During her inpatient stay she received additional IV fluids, pain control, anti-emetics, proton pump inhibitors, a gastroenterology consultation and esophagogastroduodenoscopy (EGD) with biopsies. She remained stable at all times. Her medications were transitioned to oral and she was discharged. The patient has requested reimbursement for emergency services provided. The Health Plan has denied this request indicating the patient did not receive emergency medical services. At issue in this case is whether the enrollee received emergency medical services on the date(s) 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. At the time of admission, an appropriate emergency medical work-up had been conducted such that any condition that would make her potentially unstable for transfer would have been identified. However, the patients vital signs were recorded as stable. Additionally, the patient reportedly refused transfer to an in-network facility. A thorough work-up had been conducted including appropriate laboratory testing and review of a CT scan done earlier that day. Her pain was improved after treatment in the emergency department and although not completely relieved, her condition was stable for transfer to an in-network facility for ongoing inpatient treatment and specialty consultation. There was no condition present in which transfer to an in-network hospital would have presented a danger to the patients safety or would have been likely to result in deterioration of her condition en route. Therefore, the services provided were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the services at issue were not necessary for treatment of an emergency medical condition. Therefore, the Health Plans denial should be upheld. 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.