Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ST-elevation myocardial infarction (NSTEMI)
Treatment: Non-emergency air ambulance transportation, (codes A0431x1, A0436x21 and A0398)
The insurer denied coverage for the non-emergency air ambulance transportation, (codes A0431x1, A0436x21 and A0398).
The denial is upheld. 

This is a female patient who presented to the hospital because of chest tightness. The patient has a past medical history of essential tremor, depression and elevated cholesterol, not on treatment. The patient initially felt that she had to go to the bathroom to have a bowel movement and while she was on the toilet, she began to have chest tightness. The patient had some lightheadedness. Because of the symptoms, the patient called rescue and continued to have chest tightness when she got to the hospital. The patient's initial troponin was 0.063, which trended up to 0.3 and then came down to 0.2 and then to 0.15. When seen by the Cardiology consultant, the patient still complained of mild chest tightness. The consultant's assessment and plan described the patient's chest tightness and described them as somewhat atypical. However, noted that the patient did have a positive troponin eventually to 0.3 and an electrocardiogram (EKG) showing some dynamic changes, including T wave inversions and T-wave flattening. The patient was not having a ST-elevation myocardial infarction (STEMI) but the consultant was concerned that she was having a non-ST elevation myocardial infarction (NSTEMI). The consultant recommended that the patient be transferred to another hospital for cardiac catheterization, since a coronary angiogram was not available at the initial hospital. 

The patient was transferred by air ambulance for an urgent coronary angiogram, with the indication being NSTEMI. The distance of the trip was 22.8 miles. The results were that the circulation was right dominant, there were minor luminal irregularities with no flow limiting lesions in the mid-left anterior descending (LAD), the left main, the circumflex and the right coronary artery (RCA) were normal. The patient's ejection fraction was 40% and she was diagnosed as having non-ischemic cardiomyopathy. The patient was discharged home with the following medication schedule: atorvastatin, Lasix, lisinopril and Inderal.

Areas of concern regarding air medical transport of cardiac patients include the effects of hypoxia at altitude, the effects of gas expansion at altitude, the effects of anxiety about flying, and the potential for complications related to movement of patients. Patient anxiety can have an impact on cardiovascular status during transport. Cardiac ischemia may be provoked by the elevated catecholamine levels and tachycardia that result from extreme nervousness. Those who monitored anxiety levels of patients during air medical transport noted that anxiety was greatest in anticipation of the flight. Patients with little or no experience flying were most nervous. Their level of anxiety decreased steadily during their flights. Most patients were more anxious about their medical condition than the flight itself (Essebag et al., 2003). Based on the review of the literature and medical records, ambulance transportation was not medically necessary for this patient. The patient did not have STEMI and had been asymptomatic overnight while being observed on telemetry. The patient was not seen by a Cardiology consultant until the morning following her admission. The distance between the two hospitals was 22.8 miles, which could have been reached in a relatively short time on highways. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The medical necessity for the non-emergency air ambulance transportation, (codes A0431x1, A0436x21 and A0398) is not substantiated. The insurer's denial should be upheld.