Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thoracic spine fracture
Treatment: Air ambulance services
The insurer denied coverage for air ambulance services.
The denial is upheld.

This male patient with a history of diabetes mellitus jumped into water from about a 15-meter height.  The patient was able to walk out of the area with resultant back pain.  The patient presented to the Emergency Room (ER), and his computed tomography (CT) scan found a T12 compression fracture involving first and second Denis columns and 30% loss of height.  The patient had no neurological deficit and his pain was controlled.  The patient was offered a transpedicle fixation from T11 to L1 with screws, rods and bone matrix.

The patient had a T12 compression fracture.  The patient's Glasgow Coma Score was 15.  The patient was not paralyzed and had no neurological deficits.  The patient had pain with range of motion for which the patient had a lumbar brace placed.  The patient's pain and symptom was managed with intravenous Ativan, Dilaudid and Ketorolac.

According to Sethi and Subramanian (2014), "Optimal health and well-being of the patient is the underlying goal of IHT (inter-hospital transfer).  Therefore, the decision to transfer is patient-centered and is undertaken when the benefits of transfer outweigh the risks." 

As per Rajasekaran, et al (2015), "The fracture morphology is assessed based on 3 main injury patterns: Type A (compression-injury to the vertebral body without PLC involvement), type B (tension band disruption - the failure of posterior (PLC) or anterior (anterior longitudinal ligament) constraints), and type C (displacement/translation) injuries.  Neurologic status is classified as follows: No neurologic injury (N1), radicular symptoms or deficits (N2), incomplete spinal cord injury (SCI) or any kind of cauda equina injury (N3), complete SCI (N4) and unknown neurologic status (NX).  Forty cases with a broad range of injuries were classified independently twice by group members and the reliability in the identification of a morphologic injury type was substantial (k =0.72).  The classification appears much simpler and equally comprehensive when compared with the previous AO classification and includes important information about neurology and posterior ligamentous structures.  Based on this classification, type A4, B1, B2, B3 and C injuries will need surgical stabilization.  The inter/intraobserver reliability of this classification is yet to be studied, apart from the originators."

Based on the review of the literature and medical record, the air ambulance service was not medically necessary.  The patient did not need to be transferred home, as care could have been provided at a closer facility.  The patient did not have a spinal cord trauma and was neurologically stable.  The treatment and care that this patient needed could have been provided at a closer facility, and this was not an emergent transport. 

Medicare recognizes the need for air ambulance from hospital to hospital as follows:
"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... 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 health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the air ambulance service should be upheld.  The medical necessity is not substantiated.