Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Accident. 
Treatment: Air Transport (fixed wing air mileage). 

The insurer denied the Air Transport (fixed wing air mileage). 
The denial is overturned. 

The patient is a woman. She was injured in a motor bike crash. Following her injury, she was evaluated at an out of state hospital. The patient was diagnosed as having fractures of the fifth and sixth thoracic vertebrae. These fractures resulted in a spinal cord injury. The day after her admission, the patient underwent spinal surgery to stabilize her fractures. Following her surgery, the patient remained paraplegic in both lower extremities. The patient's hospital stay was complicated by neurogenic bladder and periods of hypotension. Medical records indicate that the patient's care team advised that she be transferred to a Model System hospital for spinal cord rehabilitation following her discharge from the out of state hospital. 

The patient was transported by air ambulance to another facility out of state. Flight notes from the air ambulance crew indicate that the patient had normal vital signs and normal mental status. She had no spontaneous movements of her lower extremities. A Foley catheter was in place. There was no change in the patient's condition during transport. Medical records describing her clinical course following her transfer are not provided. 

The patient's health plan subsequently denied coverage for this air ambulance transport on the grounds that the patient was not transferred to the closest appropriate facility that could provide the care she required. The health plan writes that the patient could have been transferred to a facility in the state in which the accident took place. The patient has appealed this denial. In the appeal letter, it is written that the patient was transferred to the closest Model System hospital for spinal cord rehabilitation. 

Yes, the requested air transport was medically necessary. 

It is documented in the patient's medical records that her care team recommended inpatient rehabilitation at a Model System hospital that specializes in spinal cord rehabilitation. This was the rationale for transferring the patient to a facility in another state as opposed to a local facility that was not a Model System hospital. There is no documentation that the patient was transferred to Denver for her own convenience. She was advised to go to this facility by the acute care team managing her injuries in the state of the accident. 

Documentation refuting the recommendation that the patient receive inpatient rehabilitation at a Model System hospital for spinal cord injury is not provided. 

In reviewing a list of Model System hospitals in the Western United States that specialize in spinal cord injury, such centers can be found in several states close to the state in which the accident took place. The distance from the transferring facility to the receiving facility is 446 miles. The distance from transferring facility to another state facility is 884 miles. The distance from transferring facility to another state facility is 787 miles. The patient was transported to the nearest Model System hospital specializing in spinal cord rehabilitation. A paraplegic patient with intermittent hypotension cannot be safely transported this distance by commercial airline. An air ambulance was medically necessary to safely transport this patient from New Mexico to Denver. 

No, the health plan did not act reasonably or with sound medical judgment in denying coverage for the ground and air ambulance transfer. 

The ground and air ambulance transport services were medically necessary for the reasons described above.