Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia.
Treatment: non-emergency air ambulance transportation, codes A0426 (ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1)), A0430 (ambulance service, conventional air services, transport, one way (fixed wing)), A0434 (specialty care transport (SCT)), and A0435 (fixed wing air mileage, per statute mile).
The insurer denied coverage for non-emergency air ambulance transportation, codes A0426 (ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1)), A0430 (ambulance service, conventional air services, transport, one way (fixed wing)), A0434 (specialty care transport (SCT)), and A0435 (fixed wing air mileage, per statute mile).
The denial is overturned.

The patient was transported by air ambulance for weight restoration and medical stabilization. Initially, she reportedly presented to the hospital with poor mobility, muscle weakness, chest pain, difficulty swallowing, and had multiple abnormal labs and medical issues including hypoglycemia, low potassium, low phosphorus, elevated Liver Function Test (LFT's), lipase, amylase, transaminase, pancytopenia, pancreatitis, and bilateral lower extremity edema. She reportedly had her last menstruation months ago. She reportedly had profound malnutrition with a body mass index (BMI) at 9.8. It was reported that her weight prior to hospitalization was as low as 59lbs (pounds), which is less than 44 % (percent) of ideal body weight. She reportedly weighed 62.70 lbs. with a height of 67 inches so she was profoundly malnourished. She reportedly had been restricting food, had poor body image, excessive exercise and had reports of depression. She reportedly was cachexic with temporal wasting. She was transported by air ambulance for weight restoration and medical stabilization, as this facility was a multidisciplinary facility for treatment of patients with complex and persistent medical conditions such as this patient. 
  
This reviewer disagrees with the decision to deny coverage for air ambulance transportation as the medical records provided enough specific evidence to support that this was considered medically necessary then. This was a very medically ill patient who required cardiac monitoring, hourly blood glucose, intravenous (IV) D5NS (dextrose 5 [percent] normal saline), constant cardiac monitoring, oxygenation, and required clinicians to perform electrocardiogram (EKG's) as she was at risk for cardiac arrhythmias, hypotension, and needed 1:1 monitoring as she was profoundly malnourished with a BMI of 9.8. 

According to the DSM (Diagnostic and Statistical Manual of Mental Disorders)-5 a BMI of under 15 is considered extreme and this patient had a BMI of 9.8 so she was a considered very high risk medically. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Eating Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate. It recommends physicians take an active approach to facilitate access to eating disorder programs because specialized programs are not available in all geographic areas. It also states that determination of a patient's appropriate level of care is dependent on the patient's overall physical condition, psychology, behaviors, social circumstances in addition to weight status. The guideline also states evidence that patients with eating disorders have better outcomes when treated on inpatient units specializing in the treatment of these disorders rather than general inpatient settings where staff lack expertise and experience in treating eating disorders. During treatment it is important to monitor for shifts in weight, blood pressure, pulse, and other cardiac parameters, and behaviors likely to provoke physical decline or collapse. In severely malnourished patients, particularly with ideal body weights less than 70, they recommend cardiac monitoring. This patient had an ideal body weight below 44% prior to the hospitalization which put her at very high medical risk. She was considered at high risk for severe refeeding syndrome also as well as cardiac arrhythmias and hypotension and wasting. In this case, the patient was a high medical risk for more severe medical consequences, and she required air ambulance transportation in order to transport her safely for weight restoration and medical stabilization. This was a specialized and intensive treatment in the hospital. 

This specialized eating disorder hospital provided multidisciplinary treatment, had expertise in treating severe malnutrition, had 1:1 observation, telemetry monitoring, daily labs checked, acute and careful monitoring of refeeding, specialist consultants, psychiatric support, expert medical care, physical therapy, dietician treatment, and tube feeds, if necessary, against her will. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for non-emergency air ambulance transportation, codes A0426, A0430, A0434, and A0435 services is substantiated.