Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right lower quadrant abdominal pain. 
Treatment: Helicopter or Airplane (Air or Water) Transport (A0430). 

The insurer denied: Helicopter or Airplane (Air or Water) Transport (A0430). 
The denial is upheld. 

The patient is an adult male who presented to Mount Desert Island Hospital in Maine (ME). He was complaining of right lower quadrant abdominal pain. His past medical history was significant for hypertension and an appendectomy. Testing in the emergency department included a computed tomography scan, which raised a concern for a distal small bowel obstruction. It was unclear if this was due to adhesions or to inflammatory bowel disease. The patient was treated non-operatively with a nasogastric tube. The following day, he was feeling better. Imaging showed the passage of oral contrast into his colon, indicating that there was not a total obstruction of the small bowel. The patient was started on clear liquids. The patient expressed a desire to be transferred to New York, where he had undergone testing for similar symptoms in the past. Progress notes indicate that the patient requested the transfer and that the surgical team advised that further treatment could be given at Mount Desert Hospital. 

The patient was transported from Maine to New York Presbyterian Hospital in New York City. The patient was hypertensive, but otherwise had normal vital signs. There was no change in his condition during transport. 

The patient's health plan denied coverage for the air ambulance transfer on the grounds that it was not medically necessary. The patient has appealed this denial.  In a Letter of Medical Necessity, the physician writes that the patient was transported to receive "continuity of care" near his support system. 

The proposed treatment (air medical transport) was not medically necessary. The patient could have continued to receive treatment at Mount Desert Island Hospital. 

The patient was clinically stable. He was improving. Oral contrast from a computed tomography scan was passing into his colon, indicating that there was no complete obstruction of the small intestine. His diet was advanced to clear liquids. There was no plan for performing surgery on the patient. Continued conservative management was planned. It is documented that the patient was offered continued treatment at Mount Desert Island Hospital, but he declined. The patient requested to be transferred to a hospital in New York City. The discharge summary for the patient documents that he "requested transfer to Columbia Hospital". The transfer to New York was not performed because Mount Desert Island Hospital could not provide the services he required. 

The American College of Emergency Physicians has published a Policy Statement on the appropriate and safe utilization of an air medical services (reference below). This Policy states that clinical benefit from such services may be provided when 
1) such services meaningfully shorten the time to delivery of definitive care to patients with time sensitive medical conditions or 
2) provide necessary specialized medical expertise or equipment to patients before and/or during transport or 
3) provide transport to patients otherwise inaccessible by other means of transport. 

None of these criteria were present. There was no time sensitive medical condition present on that date. The patient was clinically stable and was improving. There is no documentation of any urgent procedure that awaited the patient immediately following transfer. There was no medical reason to shorten the time needed to transport the patient.