Emergency care is judged by what a prudent layperson would think
A plan must cover emergency services based on the symptoms a reasonable person would consider an emergency, not on the final diagnosis, and without prior authorization or in-network restriction. A denial that says 'the diagnosis was not an emergency' applies the wrong test.
When it applies
- Emergency department visits denied as 'non-emergent' after the fact
- Marketplace and individual plans (45 CFR 147.138), employer plans, Medicare Advantage (42 CFR 422.113(b))
- Out-of-network emergency care, which the No Surprises Act protects at in-network cost-sharing
Where it does not
- Scheduled care that was never presented as an emergency
- Care after the patient was stabilised, which follows normal coverage rules
The sentence to put in the appeal
“The visit was for symptoms [chest pain / severe abdominal pain / difficulty breathing / ...] that a prudent layperson with an average knowledge of health and medicine would reasonably expect to result in serious jeopardy to health absent immediate attention. Under 45 CFR 147.138(b) [and 42 CFR 422.113(b) for MA], coverage of emergency services is determined by presenting symptoms, not the final diagnosis, and may not be conditioned on prior authorization or network status.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Lead with the symptoms as presented
Triage notes and the chief complaint, quoted. The discharge diagnosis is not the point.
- Step 2
Name the rule
Most denial letters for ED visits do not mention the prudent-layperson standard because it decides the case against the plan.
- Step 3
Use external review
Emergency-care denials are within scope; independent reviewers apply the standard routinely.
Worked example
An ED visit for crushing chest pain that turned out to be costochondritis was denied as 'non-emergent'. The appeal quoted the triage note and 147.138(b); the claim was paid in full.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
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Sources
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