Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Trauma/Injuries. 
Treatment: Ambulance. 
The insurer denied the air ambulance transport. 
The denial was overturned in whole.

The patient is a female with medical history significant for depression, anxiety, post-traumatic stress disorder (PTSD) surrounding abuse suffered as a young child, previous suicide attempt, newly-diagnosed purging eating disorder, and seasonal allergies who presented to the emergency department (ED) just before midnight via Emergency Medical Services (EMS) after ingesting an unknown number of acetaminophen pills with the intention of killing herself. While the duration of time from the ingestion to the first acetaminophen level was obtained was unknown, it was likely 5-6 hours (dinner at 1800, lab drawn at about 2400). Historically, she had attempted suicide previously with acetaminophen overdose, experiencing an apparent anaphylactic reaction following administration of N-acetylcysteine (NAC). Following acute recovery, she was sent to an out-of-state program where she showed signs and symptoms of eating disorder, prompting discontinuation of her participation in the program.

Upon arrival to the ED she refused to disclose how much acetaminophen she ingested. She had a large emesis of brown material. Laboratory evaluation was significant for hypokalemia, metabolic acidosis, hyperglycemia, lactic acidosis, normal transaminases, and acetaminophen level 163. Of note, laboratory evaluation in the receiving ED was significant for lactic acidosis, worsening metabolic acidosis, elevated transaminase aspartate aminotransferase, and acetaminophen level 84. In conjunction with Poison Control, she was treated with the first dose of NAC with parenteral Benadryl for potential anaphylactic reaction, Zofran, and normal saline bolus. Arrangements were made to transfer to higher level of care at a facility equipped to manage acute acetaminophen overdose and suicide attempt.

The health plan's determination of medical necessity is overturned, in whole. 

The air ambulance transport was medically necessary for this patient.
Acetaminophen overdose is one of the more common means for attempting suicide, and if not recognized early can have dire and sometimes fatal consequences. The most important intervention following early recognition is prompt treatment with Mucomyst (N-acetylcysteine) to prevent liver injury. There is a nomogram available to guide management, and Poison Control can also be an invaluable resource for determining course of therapy. For example, at 4 hours post-ingestion, an acetaminophen level of greater than 150 is an indicator for treatment with NAC, and at 6 hours, an acetaminophen level of greater than 100 is an indicator for treatment with NAC. When this patient presented to the ED, she had ingested an unknown amount of acetaminophen and the exact length of time from ingestion was unknown, estimated by family report of dinner and arrival to the ED. Her initial level was 163, well above the limit for treatment. She was at significant risk for toxicity from her overdose as evidenced by the bump in her AST level at the receiving hospital.

This patient's transfer to an appropriate facility was an urgent situation, complicated not only by the acetaminophen overdose and potential ongoing damage from toxicity, but also by prior anaphylactic-like reaction to the treatment NAC, and suicidal ideation with attempted suicide. It was imperative that she be transferred from one facility to another over the least amount of time so as not to delay ongoing treatment, in an environment that could appropriately manage an adverse drug reaction. The distance between the two facilities was approximately 80 miles, too far for land transport given the urgency of the situation and the potential for morbidity as a result of delayed intervention. Air ambulance transport is consistent with the current standards of care.