Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Surgical site infection

Treatment: Air ambulance transfer

The insurer denied coverage for air ambulance transfer. The denial is reversed. 

This patient is a male with a past medical history of meningiomas status post resection with multiple recurrent cranium infections and subsequent multiple neurological procedures. The patient presented to the Emergency Room (ER) for the evaluation of increased purulent drainage and a slight increased size of a postoperatively poor healing wound on his scalp. The patient was found to have a wound on the right side of his scalp along the incision line that had cloudy drainage. The patient's open surgical wound was positive for staphylococcus aureus, and there was a possibility that the infection had traveled into the bones at his surgical site. The patient's providers in one state spoke to the patient's Neurosurgeon in another state and was agreed by multiple providers that the patient would be best served in latter.

Based on the review of the medical record, the transfer via non-emergent fixed-wing airplane was medically necessary. Policy states: A. Ambulance Service... Medical necessary nonemergency transportation is covered if provided by a licensed ambulance service. The patient was deemed not a candidate to fly commercial airline according to criteria set forth by the Aerospace Medical Association for travel more than 1,240 miles according to the CMS guidelines. Continuity of care in this case was of utmost importance for the best clinical outcome for the patient.

Research on continuity of care has overwhelmingly shown that established and ongoing relationships between physicians and patients have better patient outcomes, as evidenced through better quality of care and communication as well as patient trust and adherence to treatment. Additionally, literature supports that the components of continuity of care are continuity of information (knowledge of the patient's history and preferences), relationships, and management of the patient's chronic conditions. Most essential in the care of patients with complex conditions is the development of care plans and ensuring progress toward care goals by management and coordinating the patient's needs across the care continuum.

In this case, the patient's travel from one state to the other would be medically necessary given this patient's extensive history and need to continue care from his known neurosurgeon. The patient's care could not have been provided by another hospital or other provider closer as it was unknown if there were available beds and a surgeon who was willing to take this patient's case, given this patient's extensive history. Thus, this air ambulance transfer was medically necessary for the patient to receive the immediate medical care and intervention that this patient needed to safely treat this patient's medical condition.

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient. 

The carrier's denial of coverage for the air ambulance transfer from the transfer hospital in one State to the receiving hospital in another State is reversed. The medical necessity is substantiated.