Emergency Room Visit denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. Per Health and Safety Code section 1317.1, psychiatric emergency medical services are services needed to treat or diagnose a psychiatric emergency medical condition. Per that same provision, a psychiatric emergency medical condition is a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders patients as being either an immediate danger to themselves or others, or immediately unable to care for themselves due to the mental disorder. Overall, the patient demonstrated significant symptoms that warranted emergency treatment according to Health and Safety Code section 1317.1. Applying the LOCUS criteria, this patient presented with serious risk of harm (score 4), due to compromised ability to care for herself.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency room services provided on 3/14/16. 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 any medic…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency services for emergent basis or urgent basis. Findings: The physician reviewer found that at issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention. 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services on an emergent basis or urgent basis. Findings: The physician reviewer found a prudent layperson would not have sought immediate medical attention. Based on the records provided the patient’s presentation during the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented with a long history of back pain. There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy. There is no documentation submitted showing the patient’s pain rating severity. In addition, acute intervention was not warranted.

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