Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hypothyroidism, attention deficit hyperactivity disorder (ADHD), hyperlipidemia, benign prostatic hypertrophy (BPH). 

Treatment: Ambulance service, advance life support, non-emergency transport, level I, the ambulance service, conventional air services, transport, one way (fixed wing), the specialty care transport, and the fixed wing air mileage, per stature mile. 

The insurer denied coverage for ambulance service, advance life support, non-emergency transport, level I, the ambulance service, conventional air services, transport, one way (fixed wing), the specialty care transport, and the fixed wing air mileage, per stature mile. 

The denial is upheld. 

This case involves patient diagnosed with hypertension, hypothyroidism, attention deficit hyperactivity disorder (ADHD), hyperlipidemia, benign prostatic hypertrophy (BPH), coronary artery disease (CAD), and right middle cerebral artery (MCA) infarct. The patient was admitted to a rehabilitation center following a cerebrovascular accident.  There was left-sided weakness. The patient was incontinent and had back, leg, and shoulder pain.  There was also anxiety. The patient was to be transferred for acute inpatient rehabilitation. The patient was recommended for air ambulance. 

The patient was then transported to the air ambulance.  The patient was alert and oriented to person, place, time, and event and was able to follow commands and answer all questions.  There was continued left-sided weakness but was able to reposition himself on stretcher.  He was on room air and there was no IV (intravenous) access.  There were reports of pain rated 4 out of 10.  There were no noted acute issues.  The patient was then removed from the air ambulance due to malfunctioning of the air ambulance and he was resting comfortably in ambulance while waiting for decision to where they would be able to move him.  The patient was waiting for a second plane to arrive and transported him to the receiving facility.  The patient was unloaded from the ambulance and loaded into a second plane with the assistance of the crew.  The patient tolerated the departure without incident but did begin to have decreased oxygen (O2), so he was placed on supplemental O2 via nasal cannula at 2 L (liters).  Oxygen had improved with supplemental O2.  There were reports that blood pressure began to increase, and he was given scheduled medications.  The patient tolerated the flight without any difficulties or distress and remained in good spirits.  The patient remained stable through transport.  The patient was unloaded and brought to the receiving facility. 

As per nationally accepted Centers for Medicaid and Medicare (CMS) guidelines, 10.4.4 - Hospital to Hospital Transport (Rev. 1, 10-01-03) A3-3114.C.11.E, B3-2120.4.E 

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. 

The insurer's denial of coverage for ambulance service, advance life support, non emergency transport, level I, the ambulance service, conventional air services, transport, one way (fixed wing), the specialty care transport, and the fixed wing air mileage, per stature mile is upheld. Medical Necessity is not substantiated.