Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa

Treatment: Air Ambulance

The insurer denied the air ambulance transfer. The denial was reversed.   

This is a female patient with a history of anorexia nervosa, bradycardia, orthostatic hypotension, osteopenia, gastroesophageal reflux disease (GERD), irritable bowel syndrome, constipation, diarrhea, amenorrhea, depression with suicide ideations.   It was reported that she had several previous inpatient admissions for her eating disorder. She had been hospitalized due to noncompliance with residential treatment for her food behaviors and restricted food intake; she gained 1-2 pounds in one month. A request for air ambulance transfer was made for a facility that specializes in eating disorder treatment.  

This reviewer disagrees with the decision to deny coverage for air ambulance transportation to a facility that specializes in eating disorder treatment.  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 low body weights, and her body weight was 71.5% of her ideal body weight.  She had a BMI of 14.3 which is considered extreme anorexia nervosa according to the DSM-5 Diagnostic Criteria so she was considered at high medical risk as a result and in need of air ambulance transportation.  Even if she refused monitoring on the flight, it was still available if a medical emergency or psychiatric emergency arose as she was considered a high medical risk.  Her ideal body weight also was low and she had a medical history significant for bradycardia, orthostatic hypotension, osteopenia, GERD, irritable bowel syndrome, constipation, diarrhea, and amenorrhea. 

The APA Practice Guidelines for the Treatment of Patients with Eating Disorders also reports that severe refeeding syndromes can occur including fluid overload and congestive heart failure and states that physicians should take a positive approach to facilitate access to eating disorder programs because specialized programs are not available in all geographical areas.  It also states that care depends on medical and psychiatric issues and this patient had both.  She had past depression, suicidal ideation, and past aggression.  She reportedly had past air ambulance transfer when she was reportedly bradycardic with orthostatic hypotension and had reports of malnourishment. She also reportedly had air ambulance transport in which she reportedly had medical consequences including bradycardia, orthostasis, malnourishment, and cold intolerance and also reportedly required daily NG tube feedings and pulled out her NG tube and also stated that she wanted to kill herself.  This was a high risk medical and psychiatric patient with an extreme anorexia diagnosis as her BMI was 14.3 and under 15 is considered extreme. 
No alternative facilities were listed by the insurer that was specialized for further inpatient eating disorder treatment.  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 the air ambulance transfer is reversed.  The medical necessity is substantiated.