Appeal type: Transportation
Decision: Partially Favorable

We decided that the Plan has to pay the ground ambulance transportation rate. We decided that the Plan does not have to pay for air ambulance transportation.
You asked the Plan to pay for air ambulance transportation. You say that air ambulance transport was medically necessary. The Plan says that air ambulance transport was not medically necessary.
We decided that the Plan has to pay at the ground ambulance rate.
The Plan follows Medicare rules. Medicare rules say that if a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for air ambulance transportation. Our reviewer says that ground ambulance transport was medically necessary. Our physician reviewer found that the documentation supported that the transferring hospital did not have adequate facilities to provide the medical services needed by the enrollee, including an intensive care unit (ICU). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage at the ground ambulance transportation rate have been met. Therefore, we decided that the Plan has to pay the ground ambulance rate. We also decided that the Plan does not have to pay for air ambulance transportation.
The Plan follows Medicare rules. Medicare rules say that Medicare pays for air ambulance services only if the enrollee's medical condition is such that transportation by either basic, the provision of medically necessary supplies and services or advanced life support, an emergency medical technician (EMT) intermediate or
EMT-Paramedic ground ambulance is not appropriate. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for air ambulance transportation. Our reviewer says that air ambulance transport was not medically necessary. Our physician reviewer found that air ambulance services were utilized for transportation from one hospital to another. The documentation supports that other means of transportation other than ambulance would be inappropriate and contraindicated as the enrollee required IV fluids, oxygen, and close observation during transportation. The enrollee was hemodynamically stable prior to transport and ground transport would not have posed a threat to the enrollee. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of air ambulance transportation have not been met. Therefore, we decided that the Plan does not have to pay for air ambulance transportation.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.