Appeal type: Urgent Care
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergent services from through. The Health Plan has denied this request indicating that the requested services are not emergent services for treatment of the enrollees medical condition. A review of the records indicates a diagnosis of a stage IV glioblastoma multiforme (GBM) brain tumor for this enrollee. The enrollee presented with loss of speech, difficulty reading and writing, and loss of vision, and cognition was rapidly declining. The enrollee is reported to have had intraoperative brain mapping with partial resection surgery of a very large tumor, which was causing brain swelling and mass effect, and related services during the dates of services at issue. A magnetic resonance imaging (MRI), is reported to have shown several areas of tumor in the left parietal lobe. The patient is male with speech and communication problems, as well as, visual deficits of recent onset. An MRI scan of the brain noted a large tumor in his left frontal, parietal, and temporal lobes with extension into his thalamus and insula with only a 3mm midline shift with preservation of his brain stem cisterns. He was seen by an in network neurosurgeon on who appropriately advised biopsy and was scheduled for surgery the next week. Despite the evaluation, recommendation and scheduling for surgery by the in-network neurosurgeon, multiple consults were arranged by his primary care and wife and received on. All of the consultants advised of surgery with different recommendations. The patient and wife decided on the recommendations of Dr, and ordered various studies and scheduled him for an elective surgery, which was performed that day. There was no documented, nor recorded change in his general or neurologic condition the week of the, nor immediately before his surgery. There was no documented deterioration of his neurologic condition. His surgery on the was later than the recommended surgery by the in-network neurosurgeon for the week of the.The condition of the patient before the surgery was not near death and was not performed `to save his life.` The surgery did not `restore his declining neurologic function.` That is not the goal for GBM surgery. `In general, the neurologic condition on steroids is as good as it is going to get and surgery rarely improves this.` The surgery was scheduled. The surgery was elective. The surgery was not emergency surgery. 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. The services at issue 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 requested services are 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 neurological surgery 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.