Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder-Myasthenia Gravis crisis 
Treatment: Ambulance (including Air Ambulance)-Air ambulance 
The health plan denied the Air Ambulance transport as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

The patient underwent hip replacement surgery and had a complicated post-operative course including slurred speech, dysphagia, and neck muscle weakness. This progressed to difficulty breathing and swallowing to the point that she was admitted to a hospital in Florida (FL). Her diagnosis was acute decompensated myasthenia gravis crisis. Due to respiratory decline and concerns for airway protection, she was intubated and placed on mechanical ventilation followed by placement into the intensive care unit. She contracted a nosocomial COVID-19 (coronavirus) infection which progressed to pneumonia. This was confirmed by computed tomography (CT) scan of the chest. Due to the severity of illness, plasmapheresis was indicated, however, the hospital could not provide this service and the hospital could not provide intravenous remdesivir for the COVID-19 infection. Additional facilities in the region were called but, due to the COVID-19 surge, did not have the capacity to care for the patient. A credentialed physician in New York (NY) became involved. After all regional options were exhausted, he directed and recommended an out-of-region transfer to a facility capable of caring for the patient. These services included a neurocritical intensive care unit, plasmapheresis, and intravenous remdesivir. 

The requested health service/treatment of non-emergency air ambulance transport from (FL) to New York (NY) was medically necessary in this specific situation. Due to the severity of this patient's illness, plasmapheresis was indicated, however, the hospital in FL could not provide this service. The hospital additionally could not provide intravenous Remdesivir for the COVID-19 infection. Other facilities in the region capable of performing plasmapheresis were called but, due to the COVID-19 surge, did not have the capacity to care for the patient. Not having access to such would be substantially detrimental to the patient's prognosis. 

Ahmed, et al note that myasthenia gravis (MG) is the most common disorder of the neuromuscular junction. Myasthenia crisis, defined as respiratory failure requiring mechanical ventilation in MG, is a common life-threatening complication that occurs in approximately 15% to 20% of patients with MG during their lifetime. The advent of effective mechanical ventilation, specialized neurointensive care units and the widespread use of immunotherapies have substantially altered the prognosis of myasthenic crisis. Early intubation and mechanical ventilation are perhaps the most important step in the management of myasthenic crisis. Plasma exchange may be more effective than the intravenous immunoglobulin in the treatment of myasthenic crisis involving respiratory failure. In this situation, due to a surge of the COVID-19 pandemic in the Florida region at that time, a specialized neurointensive care unit and plasma exchange was not available in the region. As these have been proven to substantially alter the prognosis of myasthenia crisis, not having access to such would be substantially detrimental to the prognosis. 

Additionally, Chen, et al noted that patients with an abnormal respiratory rate, Glasgow Coma Scale score of 8 or less, and hemo/pneumothorax benefit from helicopter emergency medical services (HEMS) transport even when ground emergency medical services (GEMS) transport was faster. This may indicate that these patients benefit primarily from HEMS care, such as advanced airway and chest trauma management, rather than simply faster transport to a trauma center.