Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries

Treatment: air ambulance inter-facility transfer

The insurer denied coverage for air ambulance inter-facility transfer.

The denial is upheld.

This patient is a male who was involved in a motor vehicle accident.  The patient had traumatic injuries to the brain, thorax, face and extremities.  The patient underwent an emergency decompressive craniotomy for left temporal parietal subdural hematoma with midline shift and intracranial pressure monitoring, tracheostomy and PEG tube.  Air transport notes were reviewed for a Glasgow Coma Scale (GCS) score of 14 and weakness to all four extremities and increased weakness on the right upper and lower extremity.  The patient had a trach and was on room air.  The patient did not require any pain medication and was monitored every 15 minutes.  The patient was transported via air ambulance for inpatient rehabilitation. As per the Provider, the patient's condition needed monitoring of his heart, blood pressure and respiratory status along with pain management, neurovascular assessment and maximum assistance, and was not in a stable condition for travel via ground ambulance.

The transfer via non-emergent fixed-wing airplane was not medically necessary for this patient.  There is a note stating "disposition: social work case management for discharge / transfer disposition to inpatient rehab...  The patient was deemed not a candidate to fly commercially. Records show that the patient needed constant monitoring and was cognitively limited. However, as is apparent, care could have been provided by another hospital or other provider closer to the area. 

As per nationally accepted Medicare guideline, "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."

ACEP states "Clinical situations for air transport in interfacility transfers are best summarized as being present when: 1) patients have diagnostic and/or therapeutic needs which cannot be met at the referring hospital, and 2) factors such as time, distance, and/or intratransport level of care requirements render ground transport nonfeasible."

Based on the discharge summary, the patient was provided with physical therapy (PT), occupational therapy (OT), and speech therapy (ST) and was discharged home with recommendations for outpatient ST. There is no data indicating that these services could not have been provided at a closer hospital. 

The air ambulance inter-facility transfer was not medically necessary for this patient. The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the air ambulance interfacility transfer should be upheld.  The medical necessity is not substantiated.