Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip contusion

Treatment: Air ambulance

The insurer denied coverage for air ambulance

The denial is upheld

 
According to the patient's medical record submitted this is the case of a young adult male who was air lifted to the hospital. As per the air records the call was started for unspecified injury of left hip, with the initial encounter being abrasion, right thigh. The medical necessity form indicated the estimated ground transport time was 60 minutes versus 22 minutes via air transport. They noted that based on assessment of this patient, emergent transportation was required because of time critical and need for monitoring via electrocardiogram (EKG). The patient signed the authorization. On scene information indicated the patient was found in the Emergency Medical Service (EMS) unit alert and oriented with a patent airway. The pulses were present and no gross hemorrhage was appreciated. The patient reported left pelvis pain with palpation. It was noted that the patient had no significant medical history and that he was riding a motorcycle and was helmeted when he went to pass a vehicle and rear ended a vehicle in the other lane. He had no loss of consciousness (LOC). The patient had some minor tachycardia but no hypotension or hypoxia. Blood Pressure prior to arrival was 163/85. On exam there was left pelvic tenderness with palpation but no deformity noted. There were several abrasions noted on the lower legs.

The vital signs during transport for this patient were stable.

The emergency department (ED) note indicated the patient was involved in a motorcycle accident. He complained of pain in his left elbow and left side of the buttock. The ED provider noted the diagnosis of left hip contusion. Computed tomography (CT) imaging of the head and C spine and of the abdomen and pelvis/thoracic and lumbar spine were done which showed no significant abnormality. There was a subcutaneous hematoma/contusion overlying the left lateral hip- otherwise no acute traumatic condition noted as well as no definite acute rib fracture noted. The patient was noted to have pain in his left hip and was able to ambulate. He was discharged in stable condition with return instructions.


Based upon the records provided to me and guidelines from the insurer as well as the clinical information provided and applicable practice guidelines, the transfer by air ambulance was not medically necessary as the patient had no loss of consciousness (LOC), no head trauma and only had pain to palpation on his left hip.  He did not have any neurologic, vascular compromise. He did not have evidence of multiple pelvic fractures. His vital signs were stable and there was no indication that he required air transport rather than ground transport. There was no indication that the sending provider/physician felt it was necessary to transport this patient via air ambulance. Furthermore, there was no indication of a certificate of medical necessity that was signed by a sending physician or provider at the site.

The patient's injuries did not endanger him to the point that he required air transport rather than ground transport. Therefore, the health plans denial determination is correct as the patient did not meet guidelines for air ambulance services. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for air ambulance (A0431, A0436) is not substantiated.