Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic melanoma stage 3 IIIC (spread to lymph nodes)

Treatment: Ambulance service (healthcare common procedure coding system (HCPCS) A0428 for ambulance service, basic life support, non-emergency transport)

The insurer denied coverage for ambulance service (healthcare common procedure coding system (HCPCS)) A0428 for ambulance service, basic life support, non-emergency transport)

The denial is overturned.

The female patient has the medical diagnoses of sudden symptoms of acute inflammatory demyelinating polyneuropathy and metastatic melanoma stage IIIC. The treating provider is requesting plan approval for ambulance service, procedure code (HCPCS) A0428. 

According to the clinical documentation provided for review, the treating provider is requesting plan approval for ambulance service, procedure code HCPCS A0428. The patient has the medical diagnoses of sudden symptoms of acute inflammatory demyelinating polyneuropathy and metastatic melanoma stage IIIC. The patient has been seen and treated for a past medical history (PMH) of metastatic melanoma stage IIIC and acute inflammatory demyelinating polyneuropathy. The patient was admitted to the hospital due to persistent weakness. The patient was previously admitted for immunotherapy treatment, but she experienced acute inflammatory demyelinating polyneuropathy. At this admission, Neurology was consulted. The treatment plan included prednisone, intravenous (IV) immunoglobulin therapy, and gabapentin. The patient was transferred to a rehabilitation (Rehab) facility for further care. In a letter her oncologist explained that the patient was discharged from the hospitals after a prolonged inpatient stay. The patient was transferred back and forth between her hospital and rehabilitation facility. The patient's mother explained that the patient is still recovering and still has some lingering issues. The condition her daughter has is acute inflammatory demyelinating polyradiculoneuropathy (AIDP). The patient's mother explained that it was not possible to transport her daughter because the patient was unable to stand or feed herself. The patient's mother also stated she has submitted medical records separately from her appeal application. The treating provider ordered ambulance service, procedure code (HCPCS) A0428.

For patients who are discharged from an acute hospital to a rehabilitation (rehab) facility these individuals are generally transported. The patients are transported via an ambulance either Basic Life Support (BLS) or Advanced Life Support (ALS) depending on medical condition. BLS was a reasonable mode of transport from an acute care hospital to a rehabilitation hospital. BLS was an appropriate way to transport this patient. The patient had no other means to get hospital and the rehab center. Therefore, the request is approved and medically necessary for this patient. 

As per CMS (Centers for Medicare & Medicaid Services) regarding the use of ambulance service for transportation:

"As stated above, medical necessity is established when the patient's condition is such that the use of any other method of transportation is contraindicated. One
may presume this requirement is met under certain circumstances, including when the 
beneficiary was bed-confined before and after the ambulance trip (see  (paragraph) 20 for the complete list of circumstances).
A beneficiary is bed-confined if he/she is:
1)  Unable to get up from bed without assistance;
2)  Unable to ambulate; and
3)  Unable to sit in a chair or wheelchair".

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

The insurer's denial of coverage for ambulance service (healthcare common procedure code system (HCPCS) A0428 for ambulance service, basic life support, non-emergency transport) is overturned. Medical Necessity is substantiated.