Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac Arrest

Treatment: Interfacility Transfer

The insurer denied coverage for interfacility transfer.

The denial is overturned.

The patient is a female with a past medical history of cardiac arrest, ischemic colitis, pneumonia, acute kidney injury, respiratory failure, dysphagia, and hemothorax.  The patient presented following a cardiac arrest in the field.  The patient had been reporting shortness of breath for approximately 1 week prior to arrest.  She had 1 syncopal episode during that time.  The patient was treated with 5 rounds of epinephrine.  The patient received tissue plasminogen activator for bilateral pulmonary emboli.  The patient was started on a heparin drip, norepinephrine, and an epinephrine drip per cardiology.  The course was complicated by a gastrointestinal bleed secondary to ischemic colitis, Pseudomonas pneumonia, and acute kidney injury (AKI) requiring hemodialysis.  The patient was transferred to a secondary hospital for continuing care that was closer to her family. 

No records are provided from primary hospital. Based on the medical records from secondary hospital, she initially presented with eyes closed, grimacing to noxious stimuli to upper extremities, no response to noxious stimuli in lower extremities. Pupils sluggish. During her course in the neurocritical care unit at secondary hospital, she had recurrent fevers, possible DRESS [Drug Rash with Eosinophilia and Systemic Symptoms] syndrome, ongoing issue of anoxic brain damage vs Posterior reversible encephalopathy syndrome (PRES), the latter with significant consequences for active treatment which remained an issue.   By the end of her time in critical care, the record states "The patient is now consistently able to open eyes to voice, follow simple commands (stick tongue out, lift b/l [bilateral] arms antigravity, squeeze, intermittently can move her b/l toes)." She was also noted to be alert and oriented to person and place, conversing, and following commands. She was transferred to the regular neuro ward and was eventually sent to a rehab facility.

The interfacility transfer admission is considered medically necessary for this patient.  As per Medicare "Transfers between hospitals occur when a patient is admitted to one hospital and is subsequently transferred to another hospital for additional treatment once the patient's condition has stabilized or a diagnosis is established."  In this patient, it is evident from her course secondary hospital that she was not stable and there remained issues regarding her final diagnosis. Furthermore, while it cannot be said with certainty that the outcome at primary hospital would have been different, it can be said that secondary hospital does provide a more robust comprehensive management of such a complex patient. Based on the primary hospital website, there is no mention of a Neurocritical care unit and the Neurology section lists 3 Neurologists. In contrast, secondary hospital has 34 Neurocritical beds and 6 listed Neurocritical specialists on their website. 

Thus, based on the above, the interfacility transfer was appropriate and the insurer denial is reversed. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the interfacility transfer performed is reversed. Medical Necessity is substantiated.