Ambulance Transport denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ambulance services provided. 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 any medical services rece…

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested ambulance services on an emergent or urgent basis for treatment of the enrollee’s medical condition. Findings: The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought ambulance transport on the date in question. In this case, the patient’s parent called 911 due to nausea, vomiting and the patient becoming unresponsive. Most likely the patient had a vasovagal (neurocardiogenic) syncope and recovered spontaneously prior to EMS arrival. In addition, the patient had already been treated for recent infectious illness and he developed the vomiting which had persisted for a protracted period of time.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested ambulance transport services on an emergent or urgent basis. Findings: The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought ambulance transport on the date in question. In this case, emergency medical services were dispatched due to intermittent abdominal pain. His vital signs were normal. He was in mild distress. He was able to ambulate with assistance to the ambulance stretcher. There is no documentation that the patient suffered from a condition that risked placing the patient’s health in serious jeopardy, causing serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. All told, the services did not meet prudent layperson criteria for emergency care.

Nature of Statutory Criteria/Case Summary: An enrollee has requested ambulance services on an emergent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought ambulance transport services on the date in question. Upon review of the submitted medical records, the patient presented with complaints of being unable to sleep for the last three weeks without reported chest pain, shortness of breath, pain, weakness, headache, loss of function, nausea, vomiting, or diarrhea. The patient’s pain scale was 0 out of 10. In a letter from the patient, he indicated that he felt like he was having a heart attack. Although the notation on the EMT report notes that there were “heart problems” this was from the patient’s history and not an acute complaint on the date in dispute.

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 Ambulance Transport, then check the rights and deadlines that apply to your plan.