Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Air Ambulance

The patient is a female with a past medical history significant for hypertension and hyperlipidemia who presented to the hospital with a sudden onset of stumbling gait followed by a syncopal episode and vomiting 45 minutes prior to arrival to the emergency department. Reportedly, when paramedics arrived at the scene, the patient's serum glucose was 230 milligrams per deciliter (mg/dL). While in the emergency department, an urgent neurology consultation was obtained, and the patient was suspected to have had an acute ischemic stroke. She was determined to be a candidate for thrombolytic therapy and was initiated on tissue plasminogen activator (TPA) and was subsequently transferred via air ambulance. The patient required transfer to a higher level hospital to be evaluated by interventional neurology/advanced neurological services that were not available in the first hospital. According to the medical records the patient's symptoms completely resolved, with TPA at the time of arrival to the receiving facility. In the receiving facility, the patient underwent a magnetic resonance imaging (MRI) scan of the brain that did not demonstrate any evidence of acute stroke. Reportedly, all of the patient's symptoms had resolved and she did not require any additional intervention. Therefore, she was discharged home. The subject under review is the medical necessity of the air ambulance. The health plan's determination of medical necessity is upheld in whole. The additional medical air transport of 40 miles was not medically necessary for this patient. During the initial evaluation in the emergency department, the patient was hemodynamically stable and had no alarming findings in the laboratory tests and the diagnostic studies. In general, specific acute treatments vary by type of stroke. They may include reperfusion (e.g., recombinant tissue plasminogen activator, thrombolysis, mechanical thrombectomy) for some ischemic strokes. In this clinical case, reperfusion was elected, therefore recombinant tissue plasminogen activator was administered. The patient was hemodynamically stable and did not require mechanical ventilation or any other life support measures. In general, common indications for aircraft utilization include surgical emergencies, conditions requiring emergency coronary intervention, and acute strokes. One of the biggest advantages of air medical transport includes decreased transport time. However, the total time to patient arrival may not actually be shorter (due to travel to airport or helipad, or collection of crew members, equipment or blood products from a facility), the amount of time the patient spends in transit is decreased due to increased speeds of air transport. This becomes particularly important in the critically ill patient and has an increased benefit the further the patient needs to travel. Additionally, aeromedical EMS may bring advanced care to the patient sooner. Both ischemic and hemorrhagic stroke victims should be transferred to comprehensive stroke centers due to the potential need for TPA (ischemic only) neurovascular or neurosurgical intervention, intubation, and monitoring of neurologic function. The receiving facility had a full-capacity endovascular suite and a group of physicians specializing in endovascular brain interventions. The closer facility also offered a specialty-trained surgical team that used minimally invasive techniques to rapidly diagnose and treat stroke.
Since the health plan approved air transfer to the closer facility, which offered advanced services to treat a stroke, there was no reason to transfer to the receiving facility, which was located farther.