Urgent 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 coverage of urgent care services. Findings: The physician reviewer found that though the initial services at issue were not required on an emergent or urgent basis, taking into context the patient’s underlying health condition supports that a prudent layperson in this circumstance would reasonably believe urgent care services were necessary to prevent serious deterioration of the his health. At issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for urgent medical services. One study notes that, “Distal radius fractures… are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. The preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results. Immobilization with or without reduction forms the mainstay of non-operative treatment.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested urgent care services. Findings: The physician reviewer found that the request indicating that the services at issue were not required on an emergent basis or urgent basis. At issue in this case is whether a prudent layperson in the patient’s circumstances would have sought immediate medical attention on. 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: A review of the record indicates that the enrollee presented to an urgent care center. The records noted a two-day intermittent fever, night sweats, and right flank pain. The enrollee was evaluated, laboratory evaluations were completed, and she was discharged home with medication therapy including an antibiotic and an anti-inflammatory. The providers assessment was pyelonephritis with tubule-interstitial nephritis.At issue in this case is whether the enrollee received emergency medical services on the date of service in question.

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