Injury denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a four corner fusion surgery with compression FT screws for treatment of the enrollee who has a history of left wrist pain. Findings: The physician reviewer found that the submitted documentation supports the requested services in this patient’s case. A study indicated that four corner fusion had been shown to be a reliable option of treatment of wrist arthritis. They concluded that four corner fusion using headless retrograde headless screws demonstrated a low complication rate and high fusion rate, and could therefore be considered a reliable surgical technique.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services for treatment of an emergency medical condition. Findings: The physician reviewer found that at issue in this case is whether the enrollee received emergency medical services on the date 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 e…

Where the denial was upheld

A 21-year-old male has requested approval for past services provided on an urgent basis for treatment of his foot fracture. Findings: The physician reviewer found that the patient sustained fractures of the right foot while outside of the Plan’s service area. The patient was involved in a motor vehicle accident and was seen in an emergency room where x-rays were obtained. He was told that he had suffered a contusion, and was discharged. Because of pain with ambulation, the patient returned to the emergency room eight days later and a CT scan was obtained. The patient was then placed in a splint and on crutches. For a few days, he had increasing calf pain. On examination, there was tenderness, no swelling, and intact neurovascular functions.

The patient is a 30-year-old male who was noted as of 3/23/03 to be in a vegetative state. He was responsive to noxious stimuli. He had no eye opening and followed no commands. Per the physician’s note of 4/12/03, the patient had spontaneous eye opening, was non-verbal, and had increased tone in all four extremities. Upon admission to an eight-week coma rehabilitation program on 4/22/03, the patient exhibited the following: spontaneous eye opening, no tracking, disconjugate gaze, inability to follow directions, decorticate posturing on the left side, decerebrate on the right side, and no spontaneous motor movement. The patient was returned to acute care on 5/2/03 for repair of a colon perforation and returned to rehabilitation on 5/9/03. He remained at the same level of functioning. As of 7/16/03, there was no change in the patient’s condition.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving injury, then check the rights and deadlines that apply to your plan.