Emergency and urgent care: 45% of denials overturned

Year by year

By treatment

Treatments with at least 20 decisions, most decisions first. Rates on fewer than 20 decisions aren’t shown.

Recent decisions

The most recent decisions in the data, half overturned and half upheld. Each shows the reviewer’s published findings.

1. Overturned 2025 · Urgent care · age 51–64 Urgent care · Cancer The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for medical services. Glioblastoma is an aggressive primary brain tumor associated with rapid progression and high morbidity and mortality…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary:A patient has requested reimbursement for medical services. Glioblastoma is an aggressive primary brain tumor associated with rapid progression and high morbidity and mortality. Clinical guidelines emphasize the importance of timely diagnosis and prompt initiation of treatment to optimize outcomes. In this case, the patient required urgent evaluation and biopsy to confirm disease progression and guide treatment. Delay in obtaining diagnostic confirmation could have resulted in rapid clinical deterioration and reduced likelihood of effective treatment. Hospital admission for urgent biopsy was appropriate based on the patient’s clinical presentation and the need for expedited diagnostic intervention. Based on the acuity of the condition and the need for immediate medical intervention, the services provided meet criteria for urgent medical services. Final Result:The reviewer determined that the services at issue were urgent medical services as defined by applicable standards. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications:The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is knowledgeable about the proposed treatment through recent or current clinical experience treating those with the same or a similar medical condition.

   Case UR25-46110

2. Overturned 2025 · Urgent care · age 51–64 Emergency room visits · Lungs and breathing The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for medical services. In this case, the patient did not receive emergency medical services. However, the patient did receive urgent medical…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for medical services. In this case, the patient did not receive emergency medical services. However, the patient did receive urgent medical services. These services were necessary to prevent serious deterioration of the health of the patient, resulting from an unforeseen illness, injury, or complication of an existing condition, for which treatment could not have been delayed until the patient returned to the plan’s service area. The patient’s symptoms continued to worsen while out of the plan’s coverage area. Eosinophilic granulomatosis with polyangiitis (EGPA) carries a significant risk of severe complications and requires urgent care. Morbidity from EGPA may be related to the disease itself but also to toxicity from medications and the psychosocial burden of chronic disease. The use of glucocorticoids and other immunosuppressive therapies in patients with EGPA has improved outcomes. Thus, the patient received urgent medical services. Final Result: The reviewer determined that the services at issue were urgent care services as defined by California law. Therefore, the Health Plan’s denial should be partially overturned. Credentials/Qualifications: The reviewer is board-certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-45662

3. Overturned 2025 · Urgent care · age 41–50 Urgent care · Bones, joints and muscles The physician reviewer found that a patient has requested reimbursement for medical services. When oral analgesics have failed, the next step in treatment involves local injection of glucocorticoids, as this patient’s provider performed. This is often…

   The physician reviewer found that a patient has requested reimbursement for medical services. When oral analgesics have failed, the next step in treatment involves local injection of glucocorticoids, as this patient’s provider performed. This is often combined with capsular dissection, which has been shown to treat pain and prevent further deterioration. Given this patient’s severe pain, other treatment options could have included oral opioids, such as oxycodone. However, this could have put the patient at risk for opioid abuse. Performing the procedure at issue urgently may have helped prevent unnecessary and dangerous opioid use. For these reasons, the patient did receive urgent medical services. Final Result: The reviewer determined that the services at issue were urgent medical services as defined by California law. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-45412

4. Overturned 2025 · Urgent care · age 65+ Urgent care · Lungs and breathing The physician reviewer found that a patient has requested reimbursement for urgent care services. The patient was experiencing failure of antibiotic therapy with disease process and symptoms. Imaging demonstrated progressive necrosis of the lung. This could…

   The physician reviewer found that a patient has requested reimbursement for urgent care services. The patient was experiencing failure of antibiotic therapy with disease process and symptoms. Imaging demonstrated progressive necrosis of the lung. This could have rapidly deteriorated and required bronchoscopy to exclude other causes and provide management strategies. Therefore, the physician acted appropriately, and the indications for urgent bronchoscopy were met and required for the treatment of the patient. All told, the patient received urgent care services, defined as services to prevent serious deterioration of the patient’s health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plan’s services area. Final Result: The reviewer determined that the services at issue were urgent care services as defined by California law. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in critical care medicine and pulmonary diseases and is actively practicing. The reviewer is an expert in the treatment of the patient’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-45117

5. Overturned 2025 · Urgent care · age 31–40 Emergency room visits · Digestive system Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services after the patient was admitted for inpatient admission. Patients with colitis may be suffering from a range of etiologies including infectious…

   Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services after the patient was admitted for inpatient admission. Patients with colitis may be suffering from a range of etiologies including infectious colitis, neutropenic colitis, drug-induced colitis, and inflammatory bowel disease. Prompt diagnosis and management of acute colitis is essential to prevent severe complications and to provide recommendations for antimicrobial therapy. Additionally, patients with diabetes who present symptoms of infections such as colitis are at higher risk of developing hyperglycemic emergencies. Thus, diabetic patients with symptoms of colitis require management in an emergency setting. In this case, this patient with a history of diabetes mellitus presented to the emergency room with symptoms of severe abdominal pain. Laboratory studies and imaging findings were suggestive of colitis. The patient was appropriately admitted for inpatient treatment and observation, administered antibiotics, and provided with pain control. All told, the patient received emergency medical services after the patient was admitted for inpatient admission. Final Result: The reviewer determined that the services at issue were emergency medical services as defined by California law. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the patient's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-44829

6. Overturned 2025 · Urgent care · age 51–64 Emergency room visits · Skin Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services after the patient was admitted for inpatient admission. This patient presented to the emergency department with arm pain, swelling, and redness…

   Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for emergency medical services after the patient was admitted for inpatient admission. This patient presented to the emergency department with arm pain, swelling, and redness. While this complaint is common, multiple emergent causes are possible, including cellulitis, abscess, and osteomyelitis. Cellulitis can lead to life-threatening illnesses such as toxic shock syndrome, compartment syndrome, sepsis, pyomyositis, and necrotizing fasciitis. Necrotizing soft tissue infections have a mortality rate of 25-35%. Treatment of osteomyelitis typically consists of long courses of antibiotics in conjunction with surgical debridement of necrotic infected tissues. Even with these extreme measures, many patients go on to develop chronic infections or sustain disease comorbidities. For example, one study showed a case of an abscess leading to infectious endocarditis. For these reasons, the patient’s emergency stay was indicated for the dates in question. His emergency medical condition was stabilized as of the end of the dates at issue. This was demonstrated by a decreasing white blood cell count, lack of fever, improvement in physical exam, and de-escalation to a single oral antibiotic. It was also noted that no compartment syndrome was present. All told, the patient did receive emergency medical services after the patient was admitted for inpatient admission. Final Result: The reviewer determined that the services at issue were emergency medical services as defined by California law. Therefore, the Health Plan’s denial should be overturned. Credentials/Qualifications: The reviewer is board-certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR25-44603

7. Upheld 2024 · Urgent care · age 51–64 Emergency room visits · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. The records indicate that this patient was being treated for a right shoulder rotator cuff tear. He underwent…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for emergency medical services. The records indicate that this patient was being treated for a right shoulder rotator cuff tear. He underwent an arthroscopic rotator cuff repair on the right side. This was noted to be an emergency operation as recently the pain became so severe that it was difficult for the patient to lift his arm. However, this was not an acute onset of right shoulder pain. The patient previously presented to his provider with right shoulder pain the previous year. As per one study “Rotator cuff pathology is a commonly encountered condition, and the natural history suggests tears increase with increasing age.” This article supports that rotator cuff pathology is a common occurrence and not a medical emergent condition. This is further corroborated by another study which noted that rotator cuff injuries are a prevalent cause of shoulder pain that affects nearly 20% of the patients in the U.S. With regard to this patient, detailed documentation is not evident regarding a condition that would meet the classification of a medical emergency. There is a notation of increased pain. However, the patient’s pain scales are not documented. The patient reported that it was difficult to use arm his but there is a lack of report that the patient could not use the arm at all. This was also evident on previous examinations when he noted pain with shoulder activity. Overall, the provided documentation does not demonstrate that delaying the right shoulder surgery performed would have caused a serious deterioration in his health. Therefore, the patient did not receive emergency medical services, defined as services to prevent serious deterioration of the patient’s health resulting from unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the Health Plan’s service area. Final Result: The reviewer determined that the services at issue were not emergency services for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR24-41138

8. Upheld 2024 · Urgent care · age 0–10 Emergency room visits · Lungs and breathing Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient care services. Many pediatric patients experience an episode or recurrent episodes of wheezing in the first six years of life, often linked to a viral…

   Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for inpatient care services. Many pediatric patients experience an episode or recurrent episodes of wheezing in the first six years of life, often linked to a viral respiratory infection. The records indicate that this pediatric patient was recently enrolled in daycare and diagnosed with viral bronchiolitis several weeks prior to presenting to the emergency department. On that date, the patient’s symptoms included cough, congestion, fever, poor appetite, and new onset wheezing with increased difficulty breathing. The patient was evaluated by his primary care provider the previous day, started on bronchodilator treatment, and given a dose of systemic corticosteroid. However, the patient continued with increased work of breathing prompting evaluation in the emergency department. The patient reportedly demonstrated some improvement following bronchodilator treatment but not sufficient for safe discharge home. Thus, it was reasonable for the providers to observe the patient for intake and stability on room air while in the emergency department. However, the patient was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. The patient did not require acute inpatient admission and could have been safely managed at a lower level of care. Therefore, the inpatient care services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for the treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board-certified in pediatrics with subspecialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR24-41126

9. Upheld 2023 · Urgent care · age 51–64 Urgent care · Bones, joints and muscles The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services provided for the treatment of right shoulder pain. The treatment of a frozen shoulder is never emergent. Researchers…

   The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for services provided for the treatment of right shoulder pain. The treatment of a frozen shoulder is never emergent. Researchers explain that patients who have failed conservative treatment for six to nine months may be offered surgical treatment as either arthroscopic capsular release or manipulation under anesthesia. In a clinical trial, researchers found no differences in outcomes at 12 months between conservative care, arthroscopic release, or manipulation under anesthesia in patients with frozen shoulder. In a rigorously designed and adequately powered study to inform clinical decisions for the treatment of frozen shoulder, a common condition in adults, researchers concluded that while these three treatments are the most frequently used in secondary care, there is uncertainty about which option works best. In this clinical setting, there is clear evidence in current medical literature that treatment of frozen shoulder is never an emergent or urgent service, given that there is a clear conservative algorithm to follow prior to proceeding with manipulation under anesthesia. Therefore, the services provided for the treatment of right shoulder pain were not urgent services, defined as services to prevent serious deterioration of the patient’s health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plan’s service area. Final Result: The reviewer determined that the services at issue were not urgent services, defined as services to prevent serious deterioration of the patient’s health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the patient returns to the plan’s service area. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

   Case UR23-40340

10. Upheld 2021 · Urgent care · age 51–64 Emergency room visits · Kidney and urinary The physician reviewer found that An enrollee has requested reimbursement for services.At issue is whether the patient received emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). “Emergency services and care”…

    The physician reviewer found that An enrollee has requested reimbursement for services.At issue is whether the patient received emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). “Emergency services and care” means 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. Please note that a screening examination in an emergency department, and any medical services received from on-call specialists in the emergency department, are, by definition, an emergency medical service.Per Health and Safety Code section 1317.1.(b), 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: (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 recommendation for prostatectomy is acceptable for the diagnosis of prostate cancer, especially in the setting of Gleason 3+3=6 disease. In this patient’s case, however, the records do not document an emergent need for intervention. There is no indication from the submitted records that the patient’s cancer diagnosis or any other medical issues or complicating factors necessitated emergent care, or that any delay in care beyond the treatment date would pose a practical risk of likelihood of harm to the patient. Therefore, the patient did not receive emergency medical services as defined in Health and Safety Code section 1317.1, subdivision (a)(1). Final Result: The reviewer determined that the services at issue were not emergency medical services as defined by California law. Therefore, the Health Plan’s denial should be upheld.

    Case UR21-36359

11. Upheld 2021 · Urgent care · age 11–20 Urgent care · Mental health Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. A mental health crisis is an acute disturbance of behavior, thought or mood of a patient which if untreated may lead to harm, either to the patient…

    Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for urgent care services. A mental health crisis is an acute disturbance of behavior, thought or mood of a patient which if untreated may lead to harm, either to the patient themself or to others in the environment. Thus, the definition of a psychiatric emergency differs from other medical emergencies in that the danger of harm to the society is weighed in determining the appropriate level of care. Mental health emergencies or crises also can include acute conditions that could quickly deteriorate into dangerousness or inability to care for self, even if those issues do not currently pose a problem. The services rendered during the time period under review do not meet the definition of urgent care services and care as defined by California law. The patient did not require services to prevent the serious deterioration of his health resulting from an unforeseen illness. The patient was under the care of a local provider, who advised the patient to establish care by his school, but this was not reportedly accomplished. In addition, the patient’s presenting symptoms do not meet the definition of a psychiatric emergency or mental health crisis. Although the patient was experiencing mental health distress as evidenced by his report of increasing depressive symptoms over a four month period, the records do not support that the patient was experiencing a mental health emergency or crisis with acute suicidal ideation with plan or intent that necessitated urgent mental health services before the patient was able to return to the Health Plan’s service area. For these reasons, the services provided were not urgent care services as defined by California law. Final Result: The reviewer determined that the services at issue were not urgent care services for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case UR21-35700

12. Upheld 2021 · Urgent care · age 51–64 Emergency room visits · Bones, joints and muscles Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services provided at Bumrungrad International Hospital in Thailand. Zaina and colleagues describe lumbar spinal stenosis as a debilitating condition associated with…

    Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for services provided at Bumrungrad International Hospital in Thailand. Zaina and colleagues describe lumbar spinal stenosis as a debilitating condition associated with degeneration of the spine with aging. The authors report that no clear benefits were observed with surgery versus non-surgical treatment, and that while the rate of side effects ranged from 10% to 24% in surgical cases, no side effects were reported for conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. Lurie and Tomkins-Lane note that given that rapid deterioration is rare and that symptoms often wax and wane or gradually improve, surgery is usually elective and considered only if sufficiently bothersome symptoms persist despite trials of less invasive interventions. In this case, the records do not reflect that the patient was experiencing rapidly worsening neurological deficits. The submitted documentation does not demonstrate that treatment could not be delayed until the patient returned to the plan’s service area. Additionally, the records do not establish that the absence of immediate medical attention would result in the patient’s health being in serious jeopardy or serious impairment to bodily functions. Therefore, the services provided at Bumrungrad International Hospital in Thailand were not (1) emergency medical services, defined 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, 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; or (3) serious dysfunction of any bodily organ or part 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; and were not (2) urgent care services, defined as services to prevent serious deterioration of the enrollee’s health resulting from an unforeseen illness or injury for which treatment cannot be delayed until the enrollee returns to the plan’s service area. Final Result: The reviewer determined that the services at issue were not emergency medical care, as defined in Health and Safety Code section 1317.1, and were not urgent care services. Therefore, the Health Plan’s denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollee’s medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.

    Case UR21-34741