Emergency Room Care denials: what the review data shows

Where the denial was overturned

The parent of a six-year-old female enrollee has requested for emergency services for treatment of the enrollee’s abdominal pain and vomiting. Findings: The physician reviewer found that She had recently been inpatient with right upper lobe pneumonia, fever and abdominal pain, and to rule out appendicitis. During that admission, she was noted to have bladder distention and urinary retention of unclear significance. Appendicitis was ruled out by the surgical service. The patient was discharged to complete a course of oral antibiotics. She was taken to the pediatrician’s office because of nausea, vomiting, and abdominal pain. The vomitus was non-bloody at that time. Her examination was remarkable only for tenderness on abdominal exam, without rebound or guarding. Tums were recommended for presumed gastritis and the family was instructed to complete the course of antibiotics.

A 23-year-old male enrollee has requested emergency services on an emergent basis for treatment of his medical condition. Findings: The physician reviewer found that the issue in this case is whether a reasonable and prudent person in the patient’s circumstances would believe he or she was experiencing an emergency medical condition requiring emergency medical services. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: placing the patient’s health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part. This patient’s symptoms met prudent layperson criteria for emergent care.

Where the denial was upheld

A 37-year-old female enrollee has requested emergency services for treatment of the presence of menstrual period over three weeks and cold symptoms. Findings: The physician reviewer found that the issue in this case is whether a prudent layperson in the enrollee’s circumstances would believe she was experiencing an emergency medical condition. California law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient’s health in serious jeopardy; (2) Serious impairment to bodily functions; (3) Serious dysfunction of any bodily organ or part.A prudent layperson experiencing vaginal bleeding for three weeks, dizziness for two weeks, and fever with a history of dysf…

The parent of a 12-year-old male has requested coverage for past emergency services. Findings: The physician reviewer found that the patient presented to the emergency room with a facial rash which was minimally itchy but not noted to be painful. The patient was afebrile, and the rest of his vital signs were normal. The rash was described by the treating physician as occurring in two patches on the right side of the face, being slightly erythematous, and having a papular component. It was not thought to be cellulitis or impetigo. The patient was given a prescription for an anti-fungal cream and discharged to follow-up with his primary care physician. At issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Emergency Room Carewhen you appeal: reviewers routinely find that denials like yours didn’t hold up.