Otitis Media: when insurers say no, reviewers often say yes

Where the denial was overturned

The parent of a then eight-year-old female enrollee has requested coverage for emergency services. Findings: The physician reviewer found that the patient was seen in the emergency department with a history of right ear pain for a couple of days associated with a fever, cough, vomiting, and a discharge from the right ear. At the time of the emergency department visit, the pain was rated as “moderate.” The physical examination revealed a temperature of 100.4 degrees, petechial lesions on the palate, and erythema of both tympanic membranes with blisters on the right tympanic membrane. No perforation of the tympanic membrane or discharge was noted in the medical records. The patient was treated with ibuprofen orally and Auralgan ear drops in the ear canal for pain. The diagnoses were otitis media and bullous otitis.

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested reimbursement for emergency services provided on 4/25/16. 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 emergency department, and an…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a balloon dilation procedure.Findings: Two of the three physician reviewers found that the requested balloon dilation procedure was not likely to be more beneficial for treatment of this enrollee’s medical condition than any other standard therapy. Researchers reported that “their study demonstrated superiority of balloon dilation of the Eustachian tube with balloon catheter [and] medical management compared to medical management alone to treat Eustachian tube dilatory dysfunction in adults.” Yet another study states that “All current studies suggest that balloon dilation of the Eustachian tube can be a helpful treatment in patients with Eustachian tube dysfunction.

A 19-year-old male enrollee has requested reimbursement for emergency services. Findings: The physician reviewer found that the patient presented to the Emergency Department (ED) in the morning of the date in question with a chief complaint of awakening “with congestion in his right ear.” The pain level was documented by the triage nurse to be 5 out of 10 or moderate pain. The treating physician noted that the patient was non-toxic and afebrile and that the “right tympanic membrane is red and dull.” No treatment was rendered in the ED. The diagnosis was right otitis media and the patient was prescribed azithromycin (an antibiotic) and Vicodin (an opioid pain medication). He was discharged from the ED with follow-up instructions to see his primary care physician if he did not improve within three days.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for otitis media was denied, the published record says the denial is worth fighting.