Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Systemic amyloidosis.

Treatment: Non-emergency air and ground ambulance services.

The insurer denied coverage for non-emergency air and ground ambulance services.

The denial is overturned.

This is a male patient with a history of atrial fibrillation, hypertension, basal cell cancer, chronic lymphocytic leukemia (CLL), recent diagnosis of systemic amyloid, pleural effusions, stage 3 chronic kidney disease (CKD), hypothyroidism, chronic diarrhea, symptomatic orthostatic hypotension, diastolic heart dysfunction, congestive heart failure, and moderate pulmonary hypertension. The patient developed a blood disorder, Waldenstrom macroglobulinemia and subsequent development of systemic amyloidosis. This was proven by biopsy of the duodenum and there was likely involvement in the esophagus, gastrointestinal (GI) tract, heart and kidneys. The patient has been treated with conventional systemic oncologic therapy with several individual regimes in the past.

The patient was admitted to the hospital for acute treatment. While he was there, he suffered a "stormy" course including the developments of life-threatening gram negative sepsis requiring prolonged intensive care unit (ICU) monitoring, continual anti-diarrheal medications, vasopressors, intravenous (IV) daily fluids, IV albumin, pain medication, nasal oxygen supplementation for shortness of breath from several causes; the patient's orthostatic hypotension was significant with systolic blood pressures in the 60 to 80 range.
  
At the end of this patient's inpatient stay, his condition was tenuous at best and a decision was made to have his care transferred to a hospital in another state. Each of these hospitals does not necessarily have experimental studies that are offered in both institutions. Phase 1, 2 and 3 studies are different in each institution depending on their cooperating research groups. With this understanding it was very reasonable for one to use a different institution of excellence for their treatment. With this in mind, there can be very little debate that this patient was in no medical condition to safely travel by ambulance or commercial aircraft without expert trained professionals at his side at all times. This medical aid was essential for this patient's trip to provide for almost inevitable eventualities in his medical condition. According to nationally accepted guideline, the Centers for Medicare & Medicaid Services (CMS), air ambulance transport is covered for the transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiary's health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all types of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. The patient met these criteria. 

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

Based on the above, the medical necessity for the non-emergency air and ground ambulance services is substantiated. The insurer's denial should be overturned.