Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia nervosa

Treatment: A0426 Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) and A0430 Ambulance service, conventional air services, transport, one way (fixed wing)

The insurer denied coverage for A0426 Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) and A0430 Ambulance service, conventional air services, transport, one way (fixed wing). The denial was reversed.

This patient is a female who had air ambulance transport from a hospital to a facility for eating disorders. This patient reportedly had anorexia nervosa as a diagnosis and was in an inpatient eating disorder program and still not able to gain the necessary weight and still had symptomatic bradycardia with a heart rate as low as 32. She was transferred from one facility where she was treated for several months for her eating disorder symptoms and still had reports of low weight there. She expressed suicidal thoughts there and was transferred for a psychiatric admission but was noted to be severely bradycardic at 30's and she then was admitted to telemetry and then referred to the eating disorder specialized inpatient program for eating disorders.

The insurer denied coverage for air ambulance transport.

This reviewer disagrees with the decision to deny coverage for air ambulance transport as the chart notes provided enough specific evidence to support that she was considered a medical risk and in need of transportation of these air ambulance services due to her medical consequences and eating disorder behaviors related to her anorexia nervosa.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders report that the least restrictive level of care for safe and effective treatment is appropriate.  It also reports that during treatment it is important to monitor for shifts in weight, blood pressure, pulse, and other cardiac parameters, and behaviors likely to provoke physical decline or collapse.  It also reports that in severely malnourished patients, particularly with ideal body weights less than 70, they recommend cardiac monitoring. The eating disorder facility reportedly has a high volume of multidisciplinary expertise in eating disorders.  She required a more specialized inpatient eating disorder program as she was not making enough progress in her previous program.

The patient had a long history of inpatient treatment without reported sustained efficacy and she had a complex and severe illness in the form of anorexia nervosa with severe malnutrition and significant medical consequences related to her eating disorder.  She appeared to be too unstable medically and even psychiatrically for ground transportation and required this air ambulance transportation for rapid transport to a very specialized eating disorder inpatient treatment.

As a result, the result, the recommendation is to reverse the previous decision and approve coverage for air ambulance as medically necessary.  It did not appear that the health care plan acted reasonably or in the best interests of the patient then. 
 
The carrier's denial of coverage for air ambulance services provided using the following codes: A0426 Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) and A0430 Ambulance service, conventional air services, transport, one way (fixed wing) is reversed.  The medical necessity is substantiated.