Diagnosis: Laceration Without Foreign Body, Left Foot (S91.312D)

Treatment: emergency room visit (99283)

The insurer denied coverage for emergency room visit (99283)

The denial is upheld

This case involves a female who presented to the emergency department for suture removal. The documentation provided from the emergency department indicated the patient was seen to remove sutures which were placed on a few weeks ago. She indicated she has been washing the wound twice a day and applying ointment. She reported no issues with the wound. She denied any bleeding or drainage. The submitted documentation indicated on physical examination the patient was well-appearing. She had a well-healing wound to the dorsum of the left foot. Sutures were in place and there was no dehiscence, erythema, or drainage. The wound appeared clean dry and intact, and the patient had full active and passive range of motion. The patient did undergo suture removal and 7 sutures were successfully removed without complication.

This matter involves a denial for emergency services. 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."

The visit involved removal of sutures, which was not sudden in onset or involve risk of death, serious impairment or disfiguration to any body part. Patient's appeal states she was told to go to the emergency room because of severe bleeding from the wound, but this is inconsistent with the medical record from the day which states the patient reported no complications from the wound, and was clean, dry, intact when examined by the provider. For these reasons suture removal could have been addressed in the office rather than the emergency department.

The health plan acted reasonably with sound medical judgment.

The insurer's denial of coverage for the emergency room visit (99283) is upheld. The prudent layperson standard was not met.