Diagnosis: Removal of wound staples.
Treatment: Emergency Room (ER) visit.

The insurer denied coverage for the ER visit. The denial is upheld.

This is a female patient who presented to the Emergency Room (ER) for removal of wound staples. As per the appeal letter, the patient had fallen and sustained a laceration to the right temple and had undergone a laceration repair. As per ER notes, the patient was stable with no clinical signs of infection or pain.

Section 4900(c) of the New York State Insurance Law describes an emergency condition as "a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in: 1) Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; 2) Serious impairment to such person's bodily functions; 3) Serious dysfunction of any bodily organ or part of such person; or 4) Serious disfigurement of such person."

As per review of the medical record and literature, ER treatment for staples removal is not considered medically necessary for this patient. The criteria listed in Section 4900 of the New York State Insurance Law are not met. The patient's health was not in serious jeopardy. The patient had staples in place that could have been removed in a physician's office. The staples did not require emergent removal to prevent serious loss of function, disfigurement or damage to an organ system. Staples are routinely removed in an outpatient office setting. The patient had no complaints. The patient was not having pain or signs of infection. Staple removal does not need to be performed in the ER. Thus, the ER visit was not medically necessary.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the ER visit should be upheld. The medical necessity is not substantiated.