Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes, pancreatitis, partial pancreatectomy, splenectomy, kidney stones, and neuro-endocrine cancer.
Treatment:  Air ambulance (codes A0435, A0430).

The insurer denied coverage for air ambulance (codes A0435, A0430).  The denial is upheld.

The patient was an adult with a history of metastatic neuroendocrine tumors (NET). The patient was transferred via air ambulance for hospice services. There is no justification for air transport for a terminal patient on comfort care measures. The use of medical transport should only be used to transfer a patient to the nearest facility that is able to provide care for the individual. As this patient was medically stable on comfort measures only, air transport was not necessary.

"The decision to use air medical transport has many considerations. Ultimately, will transporting the patient by helicopter or airplane benefit the patient? While aircraft can travel at much faster speeds than ground transportation, there is a loss of time for setting up a landing zone (or transporting to an airport) and evaluation by the flight crew. Would it be a comparable transport time just to 'load and go' by ground transportation? Also, will the patient's condition be better served by a higher level of care or greater scope of practice that might be provided by the air medical transport crew? The benefits have to be weighed against the risks" (Steenhoff, T. C., and Zohn, S. F., 2019).

"As regional systems of specialty care continue to develop, transferring patients from outlying community hospitals to regional referral centers becomes increasingly common. Many conditions requiring specialty care are time-dependent, including cardiac, stroke, and trauma care. Transferring patients between medical facilities poses specific medical and legal implications. Notably, Emergency Medical Treatment and Active Labor Act (EMTALA) will likely apply, and it is important for sending and receiving physicians to understand their obligations under that law. The sending physician must stabilize the patient to the best capability of that hospital before the transfer. That physician is also ultimately responsible for choosing the mode of transportation, level of care to be provided during the transfer, and treatment orders if needed or requested. Common indications for aircraft utilization include surgical emergencies, conditions requiring emergency coronary intervention, and acute strokes. Several organizations have provided guidance on the indications for Emergency Medical Services (EMS) aircraft utilization, including the Air Medical Physicians Association (AMPA), the National Association of EMS Physicians (NAEMSP), and the American College of Surgeons Committee on Trauma (ACS COT)."  (Loyd, J.W., &amp; Swanson, D., 2018).

"Many organizations, including the American College of Emergency Physicians (ACEP), National Association of EMS Physicians (NAEMSP), and Air Medical Physician Association (AMPA), have recommendations for appropriate utilization of Helicopter Emergency Services (HEMS). When considering HEMS activation, evaluation of the following items, as outlined by the NAEMSP, can help determine appropriate HEMS activation: From a clinical standpoint, does the patient require minimal transport time outside of the hospital or critical care setting? Are there time critical evaluations or treatments for the patient which are required but unavailable at the referring facility? It must be kept in mind that recommendations for HEMS activation are not intended to replace clinical judgment, nor are they intended to be the sole determinators as to which patients should be transported by HEMS units" (Godfrey, A., and Loyd, J. W., 2018).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for air ambulance (codes A0435, A0430) is not substantiated.