Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer 

The patient is a 32-year-old male who has a past history that includes attention deficit/hyperactivity disorder. The patient has requested reimbursement for air wing transport provided on 1/12/21. The Health Insurer has denied this request and reported that the services at issue were not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination. The physician reviewer found that functional impairments due to traumatically acquired brain insults can be profound, particularly in the setting of severe injuries and in the setting of intracerebral hemorrhage. Traumatic brain injury, notably, is a major cause of disability in adults. While there is some natural recovery following acute traumatic brain injury, the impairments associated with this condition, nevertheless, are also generally amenable, at least in part, to various rehabilitation interventions.
Formal rehabilitation in a setting that is appropriate for the patientas level of dysfunction and clinical needs is the standard of care for this condition. Options for setting of care following the acute hospitalization include long-term acute care hospitals, acute inpatient rehabilitation facilities and skilled nursing facilities. Treatment centers around efforts to improve function, foster neurological recovery, mitigate risk of complications, advise on appropriate durable medical equipment, train family members/caregivers, and aid in the transition back to the community when feasible. There may be a limit, however, to the benefits of intensive rehabilitation to promote recovery significantly greater than natural recovery. The evidence base for rehabilitation following traumatic brain injury remains limited, particularly with respect to promoting function. In this case, the patient sustained a severe, acute traumatic brain injury due to a skateboarding-related fall. His course was complicated by seizures. He had persistent cognitive and safety-related impairments. He was eventually stabilized sufficiently from a medical standpoint for rehabilitation-focused care. Due to these deficits, he did require inpatient rehabilitation services. There was, however, no medical necessity of a transfer of the patient by air ambulance from the acute hospital in his residential state of Florida to a rehabilitation facility in the state of Georgia. The patientas acute hospital was in Delray Beach, Florida. This acute hospital has an acute inpatient rehabilitation facility on its own campus (Pinecrest Rehabilitation Hospital), which is Commission on Accreditation of Rehabilitation Facilities (CARF) accredited for both brain and spinal cord injury inpatient rehabilitation. There are also multiple other acute inpatient rehabilitation facilities in that region that are easily accessible by ground ambulance. The acute hospital in Delray Beach, Florida for instance, is about 55 miles away from Miami, Florida, which is a very large metropolitan area with multiple acute inpatient rehabilitation facilities that can manage brain injury rehabilitation (e.g., Mount Sinai Medical Center [Miami Beach, Florida] and Encompass Health Rehabilitation Hospital of Miami [Miami, Florida]). The transfer of the patient by air ambulance from Florida to Georgia for inpatient rehabilitation was elective, non-emergent and not medically necessary. Therefore, air wing transport provided on 1/12/21 was not medically necessary for the treatment of this patient.