Appeal type: Medical necessity
Decision: Overturned

This is a patient with a diagnosis of anorexia nervosa, restricting subtype (ANR). In addition to ANR, the patient suffered from anxiety, malnutrition, and osteopenia/osteoporosis. The case notes document that the patient has suffered from severe anorexia nervosa for about 10 years, with multiple inpatient admissions, all unsuccessful in weight restoration and returning the patient to a healthy mental state. The patient was consistently uncooperative, refusing treatment, attempting to leave against medical advice (AMA), insisting she did not need treatment. When she presented to the hospital for an evaluation, she was determined to be withdrawn, anxious, and very medically compromised with bradycardia, medical malnutrition, and multiple metabolic abnormalities. She had a body mass index (BMI) of 12. At the facility she was transferred to she was medically assessed with daily labs and correction of metabolic abnormalities. She required a 1:1 sitter and was treated under a medical hold. Her caloric intake increased rapidly from 1,400 calories per day to 3,800 calories per day. She received individual psychotherapy 5 days a week. The issue for review is whether the health service of fixed wing air transport and fixed wing air mileage (1441 miles)  was medically necessary. 

The health plan's determination is overturned. This patient was chronically and severely ill with a BMI of 12 that is very low and often associated with imminent death. The acute care hospital is an experienced facility that was not able to provide adequate care for the patient, indicative of the severity of her condition. The facility she was transferred to is the most experienced center in the United States (US) for treatment of severely medically compromised eating disorders patients. The fact that the acute care hospital had to provide a 1:1 sitter indicates how probable it was that the patient would engage in further weight reducing activities. Ground transportation would take about 24 hours, an unacceptable amount of time. Commercial aircraft are not equipped to provide the continuous monitoring and emergent interventional care that this patient may likely have required. 

Four factors need to be considered: the medical condition of the patient, the choice of hospital destination, the means of getting there, and the degree of cooperation of the patient. First, the medical status of the patient was severely compromised. Patients with this degree of medical compromise are at risk for sudden death. During the long distance flight, the patient required monitoring of her heart rate and blood pressure. She had hourly glucose checks with her blood sugar noted to be 56 at one point and she became irritated, emotional and angry when the medical crew informed her they would need to start IV fluid and administer Dextrose via IV per protocol. Secondly, the choice of the hospital destination was appropriate. The hospital the patient was transferred to is considered the best and most appropriate hospital program for the treatment of severe ANR, and has achieved a reputation for stabilizing and improving the condition of the most ill and medically compromised eating disorder patients. 
Patients with anorexia nervosa have a ten-fold increase in death rate. (1) Refeeding of patients with anorexia nervosa must be done slowly by experienced clinicians with daily management. ACUTE is the best facility for this patient. (2) The addition of a parent support group enhances outpatient treatment. (3)
Ground transportation would take a total of 24 hours with multiple stops required. This mode would be extremely hazardous and not acceptable for this patient. Commercial air would also not be acceptable. No other means of transport would be quicker or involve a shorter distance. Ground transportation and commercial air flights would all be associated with longer distances.