Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anorexia Nervosa
Treatment: Ambulance transportation (air and ground)

The insurer denied: Ambulance transportation (air and ground)
The denial is: Upheld

The patient is a female with a history of anorexia nervosa, restricting type, obsessive-compulsive disorder (OCD), generalized anxiety disorder, post-traumatic stress disorder (PTSD), psychogenic nonepileptic seizure, and gastroparesis who was initially admitted to the eating disorder unit for weight and nutritional restoration. The course was complicated by recurrent psychogenic nonepileptic seizures (formerly known as "Pseudoseizures"). Multiple electroencephalograms (EEGs) were performed without evidence of epileptic activity. A Jejunostomy (J) tube was placed multiple times and the patient would tolerate tube feeds but then would refuse such. The psychiatrist deemed the patient lacked the mental capacity to refuse tube feeds. Due to recurrently removing the tube feed, the patient was admitted to the medical floor. The admitting impression included psychogenic nonepileptic seizures, hyponatremia, anorexia with severe protein-calorie malnutrition, and likely psychogenic urinary retention. The treatment plan included benzodiazepines as needed, frequent laboratory draws, encouraging nutrition, and multiple consultations. The patient was placed in an air ambulance to be flown to a treatment center for eating disorders. The subject under review is the medical necessity for ambulance transportation (air and ground) for this patient.
Based on the clinical documentation provided, evidence-based literature, and standards of care, ambulance transportation (air and ground) services were not indicated as medically necessary for this patient.
Chen, et al. noted that patients with an abnormal respiratory rate, Glasgow Coma Scale (GCS) 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.[1] In this particular situation, clinical criteria were not met that would indicate the benefit of air transport.
In this case, the patient was admitted to a medical center and underwent a prolonged hospital stay involving psychiatric/psychological issues interfering with weight and nutritional restoration treatment. The patient was awake, alert, and not in acute distress. Hemodynamics were stable with peripheral capillary oxygen saturation (SpO2) at 97% on room air. The weight was 91 pounds (lbs.) with a body mass index (BMI) of 14.75. The dietician documented the patient was consuming and tolerating 1140 calories with 54 grams (g) of protein. Laboratory testing was essentially unremarkable without the presence of significant laboratory abnormalities. Serial electrocardiograms revealed a normal sinus rhythm without conduction abnormalities. The physical therapist recommended a discharge disposition of home without services needed. The attending physician documented that if the preferred discharge disposition was denied, the patient may need to be sent home with 24/7 nursing care or a prolonged hospital stay with feeds.
Therefore, based on the clinical documentation provided and the aforementioned evidence-based literature, requested transport is not supported as medically necessary. At the time of discharge, there were no emergent or urgent acute medical issues resulting in hemodynamic instability, significant electrocardiographic changes, or significant electrolyte abnormalities. Thus, ambulance transportation (air and ground) services were not indicated as medically necessary for this patient.