Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Trauma
Treatment: Rotary Wing Air Transport (A0431 and A0436)

The insurer denied the Rotary Wing Air Transport (A0431 and A0436).
The denial is overturned.

The patient is a male who sustained significant head and face trauma. The patient was working underneath a dump truck when a large object fell on the upper half of his body. There was no loss of consciousness. The patient did not have full memory of events.

The patient was evaluated in the ED (emergency department) of a local hospital. CT (computed tomography) scans of his head and face show that he had an open skull fracture as well as several other open facial fractures. The CT (computed tomography) scan showed pneumocephalus and possibly a small amount of subarachnoid blood. Despite these injuries, the patient was awake and alert and had stable vital signs.

The patient was treated with IV (intravenous) fluid, pain medicine and IV (intravenous) antibiotics. Following his ED (emergency department) evaluation, the decision was made to transport him to another facility, which was the closest Level One Trauma Center. It is documented in the ED (emergency department) notes that ground EMS (emergency medical services) transport would not be available for at least two hours to transport the patient. The decision was made to transport the patient by air ambulance. Flight notes from the air ambulance crew indicate that the patient had normal vital signs and normal mental status. He had a large forehead laceration which was bandaged. During the flight, the patient received medication for nausea and pain. There was no change in his condition during transport. Medical records describing the patient's clinical course following his transfer are not provided.

The patient's health plan denied coverage for the air ambulance transfer on the grounds that it was not medically necessary. The patient appealed this denial.

The letters of medical necessity indicate that the patient required transfer to another facility for surgical intervention not available at the transferring facility.

Yes, the air ambulance transport was medically necessary.
The patient sustained significant head and facial trauma. He had an open skull fracture. He had multiple open facial fractures. He required operative intervention for his injuries. It is recognized in the medical literature that open fractures should be managed surgically as soon as possible to decrease the risk of infection.

It is documented in the ED (emergency department) record from the first hospital that ground ambulance transfer would not be possible for at least two hours. The transfer itself would take approximately 80 minutes to complete. It was medically necessary to transfer this patient rapidly to a trauma center where he could have definitive surgical repair of his injuries. Delaying closure of open fractures would place the patient at risk for poor outcome, including an increased risk of infection. Delaying this patient's transfer in order to wait for ground ambulance transfer would have placed him at increased risk of infection.

No, the health plan did not act reasonably in denying coverage for this air ambulance transfer.
As ground ambulance transportation would not be available for at least two hours, air ambulance transfer was medically necessary to deliver the patient to a trauma center where he could have surgical correction of his open fractures. It was medically necessary that the surgical intervention be performed as quickly as possible to minimize the risk of infection. Delaying the patient's transfer to definitive care for two hours while awaiting ground ambulance transport would have placed him at risk for an adverse outcome.