Emergency Department Evaluation denials in California external review

What the reviewers wrote

Where the denial was overturned

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…

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency services. 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 received from…

Where the denial was upheld

A 45-year-old female enrollee has requested emergency services for the treatment of her medical condition. Findings: The physician reviewer found that the patient was evaluated in the Emergency Department for right elbow pain that commenced two weeks prior. The pain was located at the medial aspect of the elbow and worsened with range of motion. The patient was diagnosed with tendinitis. At issue in this case is whether a prudent layperson would believe she was experiencing an emergency medical condition.

The parent of an eight-year-old male enrollee has requested reimbursement for emergency services. The Health Plan has denied this request indicating that the enrollee’s condition was not emergent in nature. Findings: The physician reviewer found that the patient, a then seven-year-old male, presented to the emergency department complaining of an itchy rash on his arms and abdomen for one week. The rash began after the patient spent a night at a friend’s house, and his friend developed a similar rash. No fever, chills, headache, neck stiffness, or nausea/vomiting were noted. Vital signs were normal and he had no pain. He was evaluated by a physician who diagnosed him with a “rash” and discharged him from the ED with a prescription for hydrocortisone cream and Benadryl.

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 Emergency Department Evaluation, then check the rights and deadlines that apply to your plan.