Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic Brain Injury
Treatment: Air ambulance services
The insurer denied the air ambulance services.
The health plan's determination is upheld.

The patient is a male who is diagnosed with traumatic brain injury status post fall off the scooter. The records provided indicate the patient was un-helmeted and fell off of the scooter resulting in traumatic brain injury. It was noted that an air ambulance transported the patient from one hospital to another to receive specialized care at another facility. Records show that the insurance carrier denied coverage as air ambulance transport is only covered if the member requires transport to the closest facility, they can provide appropriate care that is not available at the originating site and when ground ambulance transportation is not medically appropriate because of the distance involved, or because the member has an unstable condition requiring medical supervision and rapid transport. Air ambulance used for member convenience or other nonclinical reasons is not covered. In this case, the member was not transported to the closest facility that could have provided the care needed. This determination was appealed and upheld as not medically necessary as the patient was not transported to the closest facility that could have provided the appropriate care.
Letters of appeal submitted state that the patient was transferred to the "most appropriate accepting facility" for him as this facility is recognized as the number one facility for rehabilitation for 27 years in a row. It was stated that traumatic brain injury victims may need extensive rehabilitation to restore lost brain function or learn how to compensate for functions that cannot be restored. At that facility, the patient could continue with comprehensive therapies including physical therapy, occupational therapy, speech and language pathology, specialized rehabilitation nursing, neuropsychology and physiatry oversight. At the time of transport, the patient was not an appropriate candidate for commercial air travel due to his compromised medical condition, traumatic brain injury, restrictions and activity tolerance. He required Intensive Care Unit (ICU) level management with continuous monitoring of his vital signs and respiratory status along with complete assistance with transport and positioning with safe measures during the flight. None of these requirements are consistent with commercial air travel. Ground transportation was contraindicated as Medicare and Medicaid services guidelines recommend ground transportation be no greater than 30-60 minutes in duration for patients such as him and the distance between the two facilities was more than 2030 miles and would have required more than 29 hours by ground ambulance. 

The patient is status post right hemicraniectomy with external ventricular drainage (EVD) placement, underwent tracheostomy and percutaneous endoscopic gastrostomy (PEG) to placement.
The patient was then discharged from long-term acute care facility via air ambulance to another facility (more than 2000 miles away) for traumatic brain injury rehabilitation treatment. However, air ambulance is only covered if the member requires transport to the closest facility, they can provide appropriate care that is not available at the originating site and when ground ambulance transportation is not medically appropriate because of the distance involved, or because the member has an unstable condition requiring medical supervision and rapid transport. The patient was noted to be stable at the time of transport and was not transported to the nearest facility that offers brain injury rehabilitation treatment. The member could have been transferred to a closer facility that provides equivalent services to treat this patient.