Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Multiple facial fractures and subarachnoid hemorrhage
Treatment: Emergency Air and Ground Transportation
The insurer denied the emergency air and ground transportation.
The denial is upheld.

The patient is an adult male with a past medical history of atrial fibrillation and cardiomyopathy. He is a resident of Illinois. He suffered facial injuries while in Florida. The patient was struck in the face by the anchor of a boat. He was taken to a hospital in Florida. In the emergency department, the patient was intubated for airway protection given his extensive facial trauma. A computed tomography (CT) scan of the head showed multiple facial fractures along with a subarachnoid hemorrhage. Following the patient's emergency department evaluation, he was admitted to the Intensive Care Unit. A neurosurgeon recommended nonoperative management of the subarachnoid hemorrhage. The patient was diagnosed as having facial nerve paralysis as well as aspiration pneumonia. He had complex facial lacerations. The patient required treatment that could not be provided at the initial hospital. The decision was made to transfer him to a hospital that could offer more advanced facial reconstructive services. Medical records indicate that the patient's family requested that he be transferred to a hospital in Illinois to be close to family. The patient was transferred by air ambulance from Florida to Illinois. The patient remained intubated and sedated during transport. The patient remained at the hospital in Illinois until his discharge. During that time, the patient underwent multiple surgeries. The patient's health plan subsequently denied coverage of this air ambulance transfer on the grounds that transferring the patient from Florida to Illinois was not medically necessary. The patient has appealed this denial.

The proposed treatment (ground and air ambulance services) was not medically necessary.

The patient was critically ill. He had suffered facial trauma as well as aspiration several days earlier. He was intubated and sedated. He had been diagnosed with a subarachnoid hemorrhage, facial nerve paralysis, multiple facial fractures and multiple facial lacerations. He required transfer to a hospital that could offer more advanced services than the initial hospital. It was medically necessary to transfer the patient to such a facility on that date.

However, transferring the patient from his hospital in Florida to a facility in Illinois was not medically necessary. This was done for the convenience of the patient and his family. There is no documentation in the medical records indicating that transfer of the patient to a facility in Florida in proximity to the initial hospital was considered. Transferring the patient almost 1000 miles was not only medically unnecessary but placed the patient at risk for an adverse outcome. Transferring a critically ill intubated and sedated patient carries significant risk. This was an unnecessary risk as the patient could have been transferred to a hospital closer to the initial hospital in Florida. 

The American College of Emergency Physicians has published a Policy Statement on the appropriate and safe utilization of an air medical services. This Policy states that clinical benefit from such services may be provided when
1) such services meaningfully shorten the time to delivery of definitive care to patients with time sensitive medical conditions or 2) provide necessary specialized medical expertise or equipment to patients before and/or during transport or 3) provide transport to patients otherwise inaccessible by other means of transport.

Shortening the time to delivery of definitive care would have involved transferring him to a hospital in Florida near the acute care facility that had managed his acute injuries. Transferring him to a hospital in Illinois delayed the delivery of definitive care for this patient.