Emergency/Urg Care denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services on an emergent 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.

The parent of a 16-year-old male enrollee requested transportation services to a residential treatment facility in Utah for treatment of the enrollee’s diagnoses of bipolar disorder, attention deficit hyperactivity disorder (ADHD) and mood disorder. Findings: The physician reviewer found that according to the documentation submitted for review, the patient was reported to have threatened family members and laid hands on his four-year-old sibling. The sheriff was called. The enrollee was status post three days in juvenile hall after striking his mother in the head and having been arrested for assault and battery. The enrollee had stated that he wanted to return to juvenile hall and join a gang, and it was felt that his mother needed protection. Subsequently, it was reported that the patient had yanked his mother’s head back while driving at 60 mph with the four other children in the car.

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.

Nature of Statutory Criteria/Case Summary: A 29-year-old female enrollee has requested reimbursement for emergency services. The patient is a 29-year-old female with a medical history significant for Crohn’s disease who presented to the emergency department with severe abdominal pain. The pain had been present for 1.5 weeks but had worsened over the prior two days. She was treated and discharged earlier the same day in an in-network emergency department. She was reportedly diagnosed with inflammation in her colon and was to follow-up as an outpatient with her provider. Her pain was noted to be 10/10 in severity at the time of presentation. Her emergency department evaluation included a complete blood count, chemistries, urinalysis, pregnancy test, lipase level and review of the computed tomography (CT) scan results from the earlier emergency room visit.

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/urg care, then check the rights and deadlines that apply to your plan.