Appeal type: Medical Necessity
Decision: Overturned

Summary Reviewer 

A 46-year-old male enrollee has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis. The physician reviewer found the patient is a 46-year-old male who was evaluated in the emergency department at 14:31 on 7/2/17 with complaints of chest discomfort that had persisted for a couple of weeks. His pain was intermittent, and radiated to his left arm and jaw. He described his pain as heaviness and pressure that was moderate in intensity. His pain was accompanied by shortness of breath and diaphoresis. He had experienced tingling to the left face. The patient indicated that he initially thought his symptoms were due to discontinuing temazepam, but his symptoms had persisted. The patients medical history is significant for diabetes. His family history includes coronary artery disease. Differential diagnoses considered included unstable angina, pulmonary embolism, and atypical chest pain. The patients heart sounds were regular, normal perfusion was present and lungs were clear with unlabored respirations. An electrocardiogram (EKG) did not reveal any acute ischemia. A chest x-ray was negative for acute disease. Laboratory data was significant for an elevated D-dimer and a normal Troponin. A computed tomography (CT) angiogram of the chest did not show any evidence of pulmonary embolism. The patient was medicated with oral aspirin and sublingual nitroglycerin. He was admitted to observation unit on telemetry. The patient has requested reimbursement for emergency services provided on 7/2/17. The Health Insurer has denied this request indicating the services at issue were not required on an emergent basis.At issue in this case is whether a prudent layperson in the patients circumstances would believe he or she was experiencing 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 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.The patients symptoms on 7/2/17 did meet the prudent layperson criteria for emergency care. A prudent layperson in the patients circumstances would reasonably expect the absence of emergency care to jeopardize his or her health. This patient presented to the emergency department after experiencing intermittent chest pain for a few weeks. Symptoms of paresthesia with an elevated D-dimer made pulmonary embolism a consideration. His symptoms were classic for acute coronary syndrome as they were described as intermittent, radiating to his arm and jaw, and associated with shortness of breath and diaphoresis. In addition, the patients significant risk factors for coronary artery disease included diabetes, obesity, and a family history of coronary artery disease. These factors, combined with the patients age, would generate a history, EKG, age, risk factors and initial troponin (HEART) score of 4. Admission is recommended for such patients as a score of 4 is associated with a 12-16% risk of an adverse cardiac event. A patient who experiences intermittent chest pain with significant cardiac risk factors meets prudent layperson criteria for an emergency. Thus, the services provided on 7/2/17 were for treatment of an emergency medical condition.