Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Concussion

Treatment: Air ambulance transport (A0435, A0430)

The insurer denied coverage for air ambulance transport (A0435, A0430)

The denial is overturned.

This is the case of a male with a history of depression.  While on a family vacation he was involved in a jet ski accident involving loss of consciousness. The medical records were provided for the patient from the local hospital. The interim report indicated the patient was involved in a jet skiing accident and sustained a concussion with some memory loss. The patient was admitted for overnight observation. Labs were included and reviewed.  Exam revealed tenderness over the manubrium. Hip x-ray revealed no fracture and computed tomography (CT) of the brain revealed no fracture. The cervical spine was negative for fracture. A chest x-ray was within normal limits. CT of the chest revealed the anterior aspect of the sternum was fractured. CT of the abdomen revealed a right nondisplaced inferior pubic rami fracture.

The air ambulance report was included which showed monitoring from 11:45 am (ante meridiem) to 15:10 pm (post meridiem). The certificate of medical necessity for air ambulance transport was signed by the physician and noted that the patient's medical condition required resources necessary to further treat the patient that were not available at the sending facility; there was significant distance to the nearest appropriate hospital making transport by ground transportation impractical or unsafe and any mode of transportation other than air ambulance would endanger the patient's health. The patient needed to be cared for by a trauma surgeon and neurosurgeon.

The air ambulance paramedic noted in the air ambulance report that the patient had a concussion with unsteady gait and now bilateral lower extremity weakness. 

There were no other closer trauma center options for the patient. The patient was admitted to the trauma center for 2 days and was found to have other injuries not diagnosed at the sending facility. Therefore, the transport meets the definition for emergency ambulance transportation. 

The transfer by air ambulance was medically necessary as the patient had sustained head trauma as well fracture to his sternum and pubic rami and needed to be monitored and evaluated at a facility that cares for trauma patients; a level 1 trauma center. The facility which he was at initially was not acceptable for this type of injury. The surgeon at the sending facility felt that it was prudent for the patient to be transferred to a level 1 trauma center to be monitored. This is the overriding feature and should be taken into consideration; the air ambulance was appropriate.  Furthermore, as noted by the air ambulance, the certificate of medical necessity was signed by the sending physician and the insurer's policy states: This coverage includes emergency ambulance transportation to a hospital when the originating facility does not have the ability to treat the emergency condition.

According to MCG General Recovery Care 25th edition Multiple Traumas, hospital admission is indicated when patients with significant multiple trauma requires inpatient care for 1 or more of the following: major surgical and post procedural care; non operative care of significant injury, multiple trauma. This patient required care at a level 1 trauma center given his head trauma, and if he decompensated needed to be monitored by a trauma service and potentially a neurosurgeon. 

The patient's life potentially could have been endangered if not transferred. Had the patient's condition deteriorated, the local hospital could not have managed him. 

There was sufficient evidence to support that the air ambulance transport (A0435, A0430) services provided were considered medically necessary.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of this patient especially since the provider felt that the patient should be transferred to a level 1 trauma center. 

The insurer's denial of coverage for the air ambulance transport (A0435, A0430is reversed. Medical necessity is substantiated.