Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hepatorenal Syndrome

Treatment: Non-emergency air and ground ambulance transportation

The insurer denied coverage for non-emergency air and ground ambulance transportation. The denial reversed.

This patient is a male with a history of NASH cirrhosis, diabetes mellitus type 2, hypertension (HTN), appendectomy, neck surgery and right wrist surgery. The patient presented to an out of state hospital while vacationing for hepatic encephalopathy. The patient was transferred to another out-of-state hospital for evaluation for a liver transplant. He was denied treatment and was returned to the original hospital for further treatment of his acute symptoms from his liver disease. The patient was treated in ICU for his hemodynamic instability. Once he was deemed medical stable for transfer, he was transported via air ambulance to a facility in his home state, for a liver transplant evaluation.

Limited medical records were provided from the initial hospital which included the fact that the patient was admitted with hepatorenal syndrome with liver decompensation. The medical hem-oncology consultation indicated the patient was transferred back to the initial hospital after having been refused a possible liver transplant because of social support system which was lacking as well as because he has renal failure. He was encephalopathic with chronic thrombocytopenia with a platelet count of 15K. The medical history included hepatic failure secondary to decompensated NASH, severe acute hepatic encephalopathy with persistent hyperammonemia, acute kidney injury likely secondary to hepatorenal syndrome, severe coagulopathy, and liver cirrhosis. Gastrointestinal (GI) and Nephrology consults were also reviewed. A progress note indicated the overall prognosis was poor especially if the patient did not receive a liver transplant and the tentative plan was to get the patient stabilized for ground ambulance transfer to Strong memorial. A progress note also indicated the patient was intubated overnight for airway protection secondary to his altered mental status. The patient was transported via air ambulance to a home state facility.

The insurer has denied coverage for the non-emergency air and ground ambulance transportation. The air ambulance record provided indicated that the patient was transported for the care of a specialist with the diagnosis being hepatorenal syndrome. Medical guidelines for airline travel, 2nd Edition May 2003 was included and reviewed. Based upon the records provided and guidelines from the insurer as well as the clinical information provided and applicable practice guidelines, the transfer by air ambulance was medically necessary as the patient had needed to travel more than 1200 miles to the transplant program to receive his evaluation and care for potential transplant.

In this situation the air ambulance services were medically necessary for this patient so that he could be cared for and evaluated in a timely fashion for a liver transplant. Therefore, it was not unreasonable to transfer this patient via air ambulance as he needed to travel such a long distance in a short period of time. The health plans denial is incorrect as the patient did require air ambulance travel. It would have been inappropriate to transfer the patient via ground transportation or to deny him transfer at all. The patient was not deemed a candidate for a liver transplant in the vacationing state and therefore had to return him home state to be cared for and evaluated for a liver transplant. The health care plan did not act reasonably and with sound medical judgment and in the best interest of this patient. 

Based on the above, the medical necessity for the non-emergency air and ground ambulance transportation is substantiated. The insurer's denial is reversed.