Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance services provided by Critical Care Medflight. Functional impairments due to traumatically acquired brain insults can be profound, particularly in the setting of severe injuries and in the setting of intracerebral hemorrhage. Eapen and colleagues note that traumatic brain injury (TBI) sequelae can lead to long-term impairments in physical, cognitive, behavioral, and social function. Per the authors, TBI rehabilitation requires an interdisciplinary holistic team approach in the management of medical complications, the prevention of further disability, and helping patients return to their highest level of independence. While there is some natural recovery following acute TBI, the impairments associated with this condition are also generally amenable to various rehabilitation interventions. Manno notes that care for the patient after intracerebral hemorrhage includes basic medical care, prevention of hematoma expansion, and treatment of potential secondary complications. Options for setting of care following the acute hospitalization include long-term acute care hospitals, acute inpatient rehabilitation facilities and skilled nursing facilities. Treatment centers around efforts to improve function, foster neurological recovery, mitigate risk of complications, advise on appropriate durable medical equipment, train family members/caregivers, and aid in the transition back to the community when feasible. There is a limit, however, to the benefits of ongoing intensive rehabilitation interventions when the impairments are protracted and profound. The evidence in current medical literature for rehabilitation following severe TBI remains limited, particularly with respect to promoting function. Gerber and colleagues note that a scoping review of clinical rehabilitation research pertaining to TBI from 1996 through 2016 identified a need for additional types of clinical research in the field of TBI clinical rehabilitation research. In this case, the patient has a history of severe acute TBI due to a fall. His course was complicated by various issues, including pneumonia, prolonged mechanical ventilation, a fall, intracerebral hemorrhage, hydrocephalus and a brain abscess. He required extensive additional treatment before eventually being stabilized sufficiently for rehabilitation-focused care. Due to the severity of his deficits and the intensity of his rehabilitative needs, he required inpatient rehabilitation services. However, air ambulance transport from Orange County Global Medical Center in Santa Ana, California to Craig Hospital in Englewood, Colorado was not medically indicated. Orange County Global Medical Center is in the greater metropolitan region of Los Angeles, California, where there are multiple acute inpatient rehabilitation facilities in the region accessible by ground ambulance. Therefore, air ambulance services provided by Critical Care Medflight were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the service at issue was not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.