## Facts

- Lois J. Wickline, a Medi-Cal beneficiary with severe vascular disease, underwent vascular reconstructive surgery and related postoperative procedures in January 1977.
- Medi-Cal authorized an initial 10-day hospital stay.
- As complications continued, the treating surgeon requested an eight-day extension of inpatient coverage.
- Medi-Cal approved only a four-day extension through utilization review.
- The treating physician did not use available appeal procedures to challenge the partial denial or provide additional supporting information.
- Wickline was discharged on January 21, 1977, consistent with the approved extension.
- After discharge, she developed severe vascular complications culminating in occlusion requiring amputation of her right leg.
- Wickline sued the State of California (Medi-Cal), alleging its actions effectively caused a premature discharge while she still needed inpatient care.

## Issues

1. Whether a third-party health care payor may be held liable in negligence for patient injury allegedly resulting from utilization review decisions limiting covered inpatient days.
2. Whether the payor’s coverage determination can be treated as a legal cause of harm when the treating physicians control discharge decisions and do not pursue available review or appeal mechanisms.

## Decision

- The Court of Appeal reversed the judgment entered on the jury verdict for Wickline.
- The court held the State (Medi-Cal) was not liable as a matter of law for the alleged negligent discharge.
- The court concluded that discharge timing and the need for continued hospitalization are medical decisions for treating physicians, and liability did not shift to the payor on these facts.

## Legal Principles

- A health care payor’s decision to limit reimbursement does not, without more, make the payor responsible for the medical judgment to discharge a patient.
- Treating physicians retain primary responsibility for patient care decisions, including whether discharge is medically appropriate notwithstanding coverage limits.
- Where review or appeal procedures exist, a physician’s failure to challenge or supplement a utilization review determination weighs against finding the payor a legal cause of injury.
- A negligence claim against a payor requires a sufficient causal link between the payor’s conduct and the injury; influence on the economic context of care is not enough when physicians make the discharge decision.

## Conclusion

The court rejected imposing negligence liability on Medi-Cal for Wickline’s injury because the utilization review decision limited payment, not medical decision-making, and the treating physicians remained responsible for discharge and did not pursue available avenues to contest or address the coverage limitation.


Wickline v. State, 192 Cal. App. 3d 1630 (Ct. App. 1986)