Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Unspecified fractures of the left and right femurs

Treatment: Air ambulance transportation services

The insurer denied coverage for the air ambulance transportation services.

The denial is overturned. 

This female patient has a history of unspecified fractures of the left and right femurs.

According to Milliman Care Guidelines (MCG) General Recovery care 25th edition multiple traumas, hospital admission is indicated when patients with significant multiple traumas requires inpatient care for 1 or more of the following: major surgical and post procedural care, non-operative care of significant injury, multiple traumas. This patient required inpatient care as soon as possible at a level 1 trauma center to assess the extent of injuries and to manage them properly and expeditiously, as the true extent of the injuries could not have been determined on the scene. 
	
Furthermore, as per MCG Health General recovery care 25th edition Musculoskeletal disease, hospital admission is needed for appropriate care of the patient because of 1 or more of the following: newly diagnosed or suspected bone, joint, muscle, or orthopedic device infection, fracture, dislocation, or other musculoskeletal injury requiring inpatient care. It was clear that this patient needed inpatient care, given the multiple injuries that were seen as well as the injuries that were not assessed until the patient presented to the level 1 trauma center. It is also clear that she needed to be taken to a level 1 trauma center expeditiously.

According to Floccare, et al, patients benefit from the appropriate utilization of helicopter emergency medical services (HEMS). EMS and regional health care systems must have and follow guidelines for HEMS utilization to facilitate proper patient selection and ensure clinical benefit. Clinical benefit can be provided by meaningfully shortening the time to delivery of definitive care to patients with time-sensitive medical conditions. 

In this case, based upon the assessment of the emergency team present at the scene, it was appropriate to use air ambulance transfer to a level 1 trauma center and to not use ground transportation which would have delayed transfer. This patient had a condition which must be construed as an emergency condition and required immediate and rapid air ambulance transportation. The patient's life potentially could have been endangered by delay in transfer via ground transportation. It was the assessment of the emergency medical team on the scene that established that this patient required immediate transfer to a level 1 trauma center and it is wrong for the insurer to assess that, in this situation (against the assessment of the professionals present at the time), that this patient did not need air ambulance transport. 

Therefore, the health plan's denial is incorrect as the patient did meet guidelines for air ambulance services. It would have been inappropriate to transfer the patient via ground transportation and to delay the assessment and treatment of this patient as the insurer wanted, as it was appropriate to transfer by air ambulance in this case.  

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for the air ambulance transportation services is overturned. The medical necessity is substantiated.