Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal Abscess.
Treatment: Air ambulance services (codes A0431 and A0436).

The insurer denied coverage for air ambulance services (codes A0431 and A0436).  The denial is upheld.

According to the patient's medical record submitted, this is the case of a patient who was air lifted to an outside hospital. The patient presented to the emergency department (ED) with complaints of 1 week history of foul liquid diarrhea, dysuria, weakness and low-grade fever. The patient denied nausea or vomiting. Intravenous (IV) antibiotics were administered in the ED. Computed tomography (CT) of the patient's abdomen showed a perirectal abscess with possible mass. Consultation for transfer to an outside medical center was obtained for further colorectal surgical services, as services were not available at sending facility. The patient was COVID positive, and white blood cell count (WBC) was 11.8. The patient was afebrile with stable vital signs. The patient's condition at time of transfer was noted to be stable.

ED documentation notes indicated that the patient was in no distress and had no complaints now. The patient was awaiting transfer. The patient was advised by the administrative team that they were unsuccessful in getting a ground ambulance transfer. Given the seriousness of the patient's condition, the patient was agreeable to flight.

At the outside hospital repeat labs were done including WBC of 9.9. Repeat CT was done which revealed perirectal fluid and stranding most consistent with infection/abscess. There was no evidence of bowel obstruction. Indeterminate liver lesion was noted, most likely benign. Mild fat stranding in the retroperitoneum and pericolic gutters is likely extension of the peri rectal process. The assessment was that repeat imaging here seems to indicate that this is more likely to be an abscess. The provider noted that it is likely that further outpatient management and follow up will be transferred to local providers.  

Air ambulance medical policy with policy number 11.01.06 for Excellus was included and reviewed. It was noted that policy includes that air ambulance is appropriate when medical condition as determined by medical director noted required immediate and rapid ambulance transportation that was necessary to minimize risk of death or deterioration of the patient's medical condition and that could not have been provided by land ambulance. Hospital to hospital transport is appropriate when transferring hospital does not have adequate facilities to provide medical services need by the patient and ground ambulance would endanger the patient's health and the medical criteria as stated in the policy statement are met. Non-emergent transportation of a stabilized patient is not considered medically necessary.

Based upon the records provided to me and guidelines from the insurer, as well as the clinical information provided and applicable practice guidelines, the transfer by air ambulance was not medically necessary, as the patient was not critical and should have been transported via ground ambulance or kept at the initial institution. The patient was stable; was not septic; and as noted by the provider in a progress note, the patient should have been able to be handled at the referring institution. There was no indication that the patient had to be transported immediately via air ambulance rather than ground transportation. 

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 services (codes A0431 and A0436) is not substantiated.