Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Depression; Suicidal ideations
Treatment: Air Medical Transport
The insurer denied: Air Medical Transport
The denial is overturned.

This case involves a teenage female, tenth grade student, diagnosed with severe major depressive disorder associated with non-suicidal self-injurious behavior (NSSIB) and suicidality. 

The patient was brought by her family and subsequently treated with acute inpatient level care for approximately 2 months with plans for transfer to another treatment facility specializing in the treatment of teens. The patient was transferred from the original facility to the receiving acute care facility in another state with use of an air ambulance transport service staffed with intervention specialists due to the patient's risk of complications due to risk for self-harming behavior and a "fragile" state, and in consideration of the distance needed to travel from one state to the other. Air Transport Flight was selected instead of a standard ambulance with ground transport service or with commercial air transport in order to mitigate the risks associated with the transfer to the accepting facility. Additionally, the health plan authorized coverage for the accepting/receiving facility which had specialty programing that would be capable of addressing the complexities of the case.

The appeal is on the basis of medical necessity indicating that medical necessity is met for non-emergency air ambulance transport and that the plan conditions of coverage are also met with regard to the plan definition of medical necessity outlined in the appeal. The appeal indicates that the denial of coverage is "unsubstantiated" and "contrary to law" together with pointing out the contradiction of authorizing treatment but issuing a denial for safe and clinically appropriate transportation to the accepting treatment facility.

The plan denial determination is on the basis of coverage exclusion and Administrative Policy governing non-emergency transport by the requested air ambulance services indicating that the requested services were excluded under the plan. The denial determination indicated that there were no safety concerns and that the patient had been stabilized with the inpatient services provided prior to the transport to the accepting facility.

The proposed treatment was medically necessary in this case.

In this case, the patient is diagnosed severe symptoms of depression with non-suicidal self-injurious behavior and suicidal risk warranting the transfer from the admitting facility to an acute care facility in another state. The air ambulance transport was clinically appropriate and reasonable in this case scenario.

The accepting treatment facility was the most appropriate treatment facility to address the complications associated with the depressive disorder and to provide the specialty comprehensive behavioral health and psychiatric services that were medically necessary and clinically appropriate for this patient. Transport by ground transport was out of the question, and commercial airline was not feasible, as outlined in the appeal and would have been dangerous in this case scenario. The receiving treatment facility is the closest treatment facility that is/was capable of addressing the extensive clinical needs of the patient, and the air ambulance transport (including ground transport) was in the patient's best interest and appropriate, and the requested benefit of air ambulance transport should be covered under the plan.

The requested transport to a specialty facility with acute and comprehensive psychiatric services for teens is consistent with prevailing standards of medical practice for the conditions under treatment in this case, and the scientific literature and published guidelines.