Emergency Department Visit 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 emergency medical services. Findings: The physician reviewer found that the patient presented to the emergency department with reports of abdominal pain located in the lower abdomen that began suddenly two days prior and had become persistent. Her symptoms commenced after eating pizza. She reported nausea, vomiting and low back pain. The patient’s past medical history included diabetes and hypercholesterolemia. Her vital signs showed a blood pressure of 122/69, temperature of 98.3 F and pulse of 72. Mild abdominal tenderness was present in all four quadrants with a positive Murphy’s sign. Laboratory data revealed ketonuria with a glucose of 144, but was unremarkable. An abdominal ultrasound was negative for gallstones or cholecystitis.

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.

Where the denial was upheld

A 65-year-old male enrollee has requested reimbursement for emergency services. Findings: The physician reviewer found that The patient is a 65-year-old male who sustained an initial fall and broke his neck and sustained right-sided weakness. He was discharged from an acute care hospital three days later and was admitted to a skilled nursing facility (SNF) the following day with a cervical collar in place. On the day of admission to the SNF or the following day the patient reportedly fell to the floor in the bathroom after slipping off the toilet. He reported no loss of consciousness or complaint of new neck pain. He was taken by ambulance from the SNF to the Emergency Department.

A 46-year-old male has requested coverage for emergency services. Findings: The physician reviewer found that the patient presented to the emergency department for evaluation of a dry cough for two weeks that was not improving. A medical screening exam was performed which revealed that he was afebrile with a normal respiratory rate, heart rate, and pulse oximetry on room air. Testing was performed to include an EKG, lab tests and a chest x-ray, but the patient left the emergency department prior to being seen by the physician on duty. Subsequently, he went to an Extended Hours Clinic and was seen by a physician assistant. Again, the patient was noted to be afebrile with a normal pulse, respiratory rate and pulse oximetry. Pain was not a presenting complaint, and no pain level was documented.

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