Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain, status post cholecystectomy surgical complications
Treatment: Air Ambulance Transport (procedure codes A0426, A0430, A0434 & A0435) 
The insurer denied the Air Ambulance Transport (procedure codes A0426, A0430, A0434 & A0435)
The denial is upheld.

The records report that the patient is a female with a history that includes sleep apnea, asthma, hypertension, coronary artery disease, morbid obesity, systemic lupus erythematous, scleroderma, anemia, fibromyalgia, generalized osteoarthrosis, cervical spine surgeries, back surgery, right foot drop, and multiple bariatric surgeries in the past.  

The patient presented to an Emergency Room with abdominal symptoms attributed to cholelithiasis.  She was discharged home with instructions to schedule a cholecystectomy.  She saw a physician as an outpatient and a cholecystectomy was scheduled for approximately a month later.

The patient returned to the Emergency Room in her home state with the same abdominal symptoms, which were attributed to biliary colic.  A family and caregiver update note noted that a person identified in the document as a "spouse" was at the patient's bedside.

The patient underwent robotic converted to laparoscopic cholecystectomy and lysis of adhesions.  She returned emergently to the operating room due to concerns for bowel injury in the setting of septic shock.  She underwent bowel resection to address an enterotomy.  She underwent multiple further abdominal surgeries for washouts, debridements and wound closure.  She received multiple courses of antibiotics and multiple blood transfusions.  She was temporarily on total parenteral nutrition before resuming an oral diet.  Her abdominal wound ultimately closed and was deemed to be healing well. Her hospital course was otherwise complicated by behavioral episodes attributed to anxiety attacks.  She refused antidepressants.  She also developed severe deconditioning.  She was transferring with contact guard assistance.  She was ambulating up to 20 feet with a walker at minimal assistance.  The plan was transfer to an inpatient rehabilitation hospital, either the acute inpatient rehabilitation hospital that is affiliated with the acute hospital, versus a rehabilitation hospital out of state (where one of the patient's daughters lives).

The patient was transferred by ground and air ambulance to an acute inpatient rehabilitation hospital out of state. She was transferred to a local acute hospital for further evaluation of a possible abdominal wall abscess.  She underwent surgical incision and drainage of an abdominal wall abscess cavity.  A vacuum-assisted closure dressing was applied.  A left kidney stent was placed for hydronephrosis.  She received antibiotics.  The abscess culture did not grow any organisms.

According to a letter of medical necessity signed by a physician at the acute hospital, it was noted that the patient lacked a support system and a decision was made to transfer her to a rehabilitation hospital out of state so she could receive provide continuity of care from her support system upon discharge from the rehabilitation hospital. She was discharged to the community with home services.

The health plan denied coverage of the air ambulance transport from the acute hospital in the home state to the acute inpatient rehabilitation hospital out of state noting that transport is not covered unless the care that a patient needs cannot be given in the patient's location.

No, the proposed air ambulance transport was not medically necessary.
The patient was hospitalized in her state of residence due to abdominal issues.  She underwent multiple surgeries and was ultimately medically stabilized, but she was severely functionally impaired.  She was an appropriate candidate for post-acute rehabilitative care.  Her medical conditions and functional impairments warranted a transition to a rehabilitation facility where her ongoing issues could be addressed and treated.  There were, however, multiple appropriate facilities for this rehabilitation within the patient's home city and state, such that air ambulance transportation to the out of state facility was not medically necessary.  Rehabilitation in the home state or in the surround metropolitan area, moreover, would have also kept her closer to the acute hospital where her physicians who had been treating her complex condition over the prior two months were present and could be consulted if needed regarding her recent care.

A transfer to a rehabilitation facility out of state was for the convenience of the patient and family, not a medical necessity.  Participation by her family and other supports who live out of state during the rehabilitation process may have been desired, but was not a requirement for the patient's inpatient rehabilitation.  Her family member(s) could have traveled to the patient's home state if they wished to provide support or participate in the rehabilitation process.  There is, notably, no documentation in the clinical records of a plan and/or records establishing the need to involve the patient's family member in the rehabilitation process prior to the transfer.  There is no documentation of any participation of any family members or caregivers during the rehabilitation course at the out of state facility in the available medical records.  There is no documentation of any family training provided in the rehabilitation facility out of state.

There was no necessity for air ambulance travel on the date of service in question in this case, as there was no medical necessity of travel from a hospital in the patient's home state to the out of state facility for inpatient rehabilitation.  The denial of coverage was reasonable and sound based on the available documentation, as discussed above.