Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intracranial Hemorrhage

Treatment: Air Ambulance Services (procedure codes A0431, A0436)

The insurer denied coverage for Air Ambulance Services (procedure codes A0431, A0436).

The denial is overturned.

 
The patient is seeking coverage for Air Ambulance Services (procedure codes A0431 and A0436).

Air transportation was requested as the patient's condition was time critical.  The patient's condition required critical life care support and monitoring including electrocardiogram.  The receiving facility provided specialized care, treatment, and diagnostics not available at the referring facility or facility that may have been closer to the scene.  The patient required interventional neurology.  The patient reported that they had become nauseous.  Then they had weakness, dizziness, and vomiting with difficulty speaking.  The patient was brought to the facility.  Imaging of the head showed a hyperdensity consistent with acute hemorrhage within the cerebellum within the midline. There is significant hemorrhage seen surrounding the cerebellar folia bilaterally.  Out of concern that the bleed may be a result of underlying vascular malformation, it was recommended that the patient be transferred to a tertiary facility where they could be observed and if necessary, an angiogram could be performed.  Immediate dispatch was completed for transfer of stroke patient going from St. Luke's Hospital to Westchester Emergency Department (ED) for neurology specialty care that was not available at the sending facility.  The drive time was 65 minutes versus flight time of 17 minutes.  The air transport was notified and dispatched 5 minutes later.  

The provider certified that the transfer by air transport was medically necessary as evidenced by the assigned physician certification statement.  The patient was suffering from bleeding in the brain which required immediate interventional radiology treatment.  The services not available at the referring facility.  Rapid and immediate transport to the receiving facility was medically necessary.  Research has shown that in cases of reduced blood flow to the brain, each minute the patient was without treatment increase the amount of brain tissue death with delay in treatment causing poor outcomes.  Ground transport was estimated to take approximately 65 minutes with transport by air taking just 17 minutes.  Therefore, the ground transport would delay the patient's access to care, threatening their survival, and endangering their health.  Thus, the transport by air ambulance was medically necessary and reasonable.  The air ambulance had all of the equipment and supplies needed to address the patient's needs including specialty critical care providers trained in advanced airway procedures.  The patient was suffering from intracranial bleeding potentially requiring advanced airway support to make another mode of transport contraindicated.  Transport by ground would endanger the patient survival and threaten their health as it would delay access to care and increased out of hospital time.  The patient was suffering from a life-threatening condition.  Air transport was more than 30 minutes faster than transport by ground.

Brain hemorrhage is a medical emergency that requires prompt treatment to prevent complications or death.  The patient had a life-threatening condition which required transport for additional management.  The drive time was more than double the air transport time.  The patient required prompt treatment and ground transport time increased risk for complications and mortality, which made the air transport medically necessary for the patient.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Air Ambulance Services (procedure codes A0431, A0436) is substantiated.