Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia nervosa; malnutrition; hypoglycemia; diabetes mellitus

Treatment: Air ambulance transfer

The insurer denied coverage for air ambulance transfer. The denial is reversed. 

This patient is a male who was transferred from a hospital in one State to an acute center for eating disorders in another State. The patient was found unresponsive at home with a blood sugar in the 30's, and was brought to the first hospital. The patient was noted to have anorexia nervosa, and had malnutrition, hypoglycemia, and diabetes mellitus, and elevated liver function tests. The patient reportedly had abdominal pain when eating, and also dysphagia. The patient reported that he had a previous eating disorder program treatment. In the hospital the patient received intravenous (IV) fluids, nasogastric (NG) tube placement, and thiamine supplementation. The patient also received Olanzapine. The patient was noted to be in the medical intensive care unit (MICU) due to hypotension. It was reported that he did not have the capacity to make decisions so the treatment team made the decision to send him to a specialized eating disorder inpatient treatment. The patient was considered a medical risk. The medical team considered that air ambulance transportation was medically appropriate mode of transportation because ground transportation was considered too far and not safe.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders reports 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. They report that severe refeeding syndromes can occur including fluid overload and congestive heart failure. 
In this case, this patient had medical consequences due to the eating disorder including hypotension, anorexia, as he was significantly underweight at 68 pounds. The patient was considered malnourished and lacking the mental capacity to make decisions. The patient was found unresponsive at home initially due to very low glucose of 30's and hypotension and required medical intensive care unit (MICU) level of care. The patient required a specialized eating disorder treatment program in Denver. He was considered a medical risk due to his low weight and malnutrition. Given this patient's fragile medical condition, the patient required air ambulance transfer. Also, the hospital was not able to provide the specialized intensive eating disorder treatment that the receiving acute center for eating disorders could provide. The care at the specialized eating disorder treatment facility was considered medically necessary treatment, and air ambulance transportation was considered medically necessary due to this patient's fragile medical and cognitive state.

The healthcare plan did not act reasonably with sound clinical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the air ambulance is reversed. The medical necessity is substantiated.