Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-Hodgkin's Lymphoma.
Treatment: Health Care Common Procedure Coding System (HCPS) code 0435 x182, fixed wing air mileage per statute mile, modifier II, HCPCS code 0434- specialty care transport (SCT) modifiers HI, II, 1N, HCPS code A0430- ambulance service, conventional air services, transport one way (fixed wing)- modifier II, and HCPS code A0426 x 2- ambulance service, advanced life support, nonemergency transport, level 1, (ALS 1)- modifiers HI, IN.

The insurer denied coverage for Health Care Common Procedure Coding System (HCPS) code 0435 x182, fixed wing air mileage per statute mile, modifier II, HCPCS code 0434- specialty care transport (SCT) modifiers HI, II, 1N, HCPS code A0430- ambulance service, conventional air services, transport one way (fixed wing)- modifier II, and HCPS code A0426 x 2- ambulance service, advanced life support, nonemergency transport, level 1, (ALS 1)- modifiers HI, IN.  The denial is upheld.

This is a male with a history of coronary artery disease (CAD), hypertension, dyslipidemia, lymphoma, cataracts, basal cell carcinoma, squamous cell carcinoma, and prostate cancer. He began treatment for Non-Hodgkin's Lymphoma. The cancer had spread to his brain and bone. The patient received chemotherapy but continued to decline. After a certain point, it was determined that he was no longer a candidate for chemotherapy and hospice care was recommended. The patient was transported by air to his home state.

Nationally accepted guidelines for Medicare provides guidance for the use of air transport. 

10.4.4 - Hospital to Hospital Transport notes that "Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiary's health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient's family prefer a specific hospital or physician."

10.4.5 - Special Coverage Rule notes, "Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician's office, or a beneficiary's home."

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.      

There is no justification for air transport for a terminal patient on comfort care measures from a world-renowned tertiary care center to a hospice service in his home state.  The use of medical transport should only be used to transfer the individual to the nearest facility that is able to provide care for the individual.  This individual was already in such a facility and hospice care services could have been provided at the world renowned tertiary care center.  There exists immediate environs multiple hospice options. Some hospice care is home - based and this obviously would not be an option for this patient who did not reside in the state. Transferring a patient form a tertiary care center home for hospice care is not identified as an appropriate use of air transport services. (Lloyd et al.)

The insurer's denial of coverage for Health Care Common Procedure Coding System (HCPS) code 0435 x182, fixed wing air mileage per statute mile, modifier II, HCPCS code 0434- specialty care transport (SCT) modifiers HI, II, 1N, HCPS code A0430- ambulance service, conventional air services, transport one way (fixed wing)- modifier II, and HCPS code A0426 x 2- ambulance service, advanced life support, nonemergency transport, level 1, (ALS 1) - modifiers HI, IN provided on 8/21/20 is upheld. Medical Necessity is not substantiated.