Emergency Room denials in California external review

What the reviewers wrote

Where the denial was overturned

The parent of a four-day-old male enrollee has requested reimbursement for emergency room services provided. 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 four-day-old male, was brought to the emergency room by his parents due to six hours of crying, decreased oral intake and concern that the patient’s skin looked yellow. The emergency room physician noted the patient looked very appropriate, interactive and otherwise well. Upon examination of the eyes, the physician indicated that he did not see any jaundice. The patient was not crying in the emergency room and was resting comfortably. His bilirubin was 9.3.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement emergency services.Acute lower gastrointestinal bleeding is supported as a medical reason for hospitalization and is associated with considerable morbidity. Diverticular disease is the most common source for lower GI bleeding. Initial evaluation for lower GI bleeding should focus on obtaining the patient's history and performing a physical examination, including evaluation of hemodynamic status. Evaluation should be based on the suspected cause of the bleeding. This patient reportedly presented to the hospital with acute pain and lower GI bleeding from an unknown source. Localization of bleeding source to upper or lower GI tract aids in determining the appropriate treatment course.

Where the denial was upheld

A 40-year-old female has requested reimbursement for emergency room services. The Health Plan has denied this request indicating that the enrollee's condition was not an emergent medical condition. Findings: The physician reviewer found that the patient presented to the emergency room (ER) with a chief complaint of tearing associated with swelling and pain in the region of the medial canthus of the right eye, present for one year, but worse since the prior day. She had been seen for this problem multiple times by her primary care provider. In the ER, her vital signs were unremarkable, and the emergency physician noted that she was in no apparent distress. No specific pain score was entered into the record by that physician. Slight swelling was noted at the medial canthus and along the right side of the nose with tenderness to palpation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency room services on an emergent or urgent basis. The physician review found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with back pain radiating to his right buttock that had been present for one week. He had not suffered any recent injury. He had no neurologic deficits. The patient was described as in no distress. Based on the patient’s presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical 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 Emergency Room, then check the rights and deadlines that apply to your plan.