Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope.
Treatment: Air Ambulance Transfer Service (A0426, A0430, A0435).
The insurer denied: Air Ambulance Transfer Service (A0426, A0430, A0435).
The denial is upheld.

The patient is an adult female physician who presented to the emergency department. The patient had fainted at home while exercising. Following her emergency department evaluation, the patient was admitted to the hospital. She had an echocardiogram that showed moderate to severe pulmonary stenosis. A magnetic resonance image (MRI) of the chest showed a mass on the pulmonic valve that was felt likely to be malignant. This mass was causing pulmonary stenosis. The patient required surgical resection of her pulmonic valve mass. The patient requested to be transferred to another hospital to have this procedure performed. It is documented in the patient's discharge summary that the patient requested transfer to be closer to family. The patient was transferred by air ambulance from the admitting hospital to the patient requested hospital. Following her transfer, the patient was admitted to the requested hospital. She underwent surgical resection of her pulmonic valve mass. She was discharged home 4 days later.
The patient's health plan subsequently denied coverage for this air ambulance transfer on the grounds that the transfer was not medically necessary. Specifically, it is pointed out that there is no evidence that the admitting hospital could not provide the surgical services that this patient required. The patient has appealed this denial.
In a Letter of Medical Necessity written by the Provider, the physician notes that the patient was transferred "to receive specialized care". There is no documentation in this letter indicating that the admitting hospital could not provide the surgical services that the patient required.

The air ambulance transfer was not medically necessary.

There is no evidence that the original admitting hospital or another facility in the area could not provide the surgical services that this patient required. This health plan states that for a service to be medically necessary it cannot be primarily for the 
convenience of the patient. The medical records clearly indicate that the patient requested transfer to another hospital to have her pulmonic valve mass resected. It is documented that the patient made this request so that she could be closer to family. There is no documentation indicating that the original admitting hospital did not have cardiothoracic surgical services that could have provided the care. There is no documentation indicating that no other hospital in the area could provide the surgical services. The documentation indicates that this transfer was made for the convenience of the patient. 
Transferring the patient by air ambulance placed her at risk of all of the complications associated with air ambulance transfer.
The American College of Emergency Physicians has published a Policy Statement on the appropriate and safe utilization of an air medical services (reference below). This Policy states that clinical benefit from such services may be provided when:
1- such services meaningfully shorten the time to delivery of definitive care to patients with time sensitive medical conditions or
2- provide necessary specialized medical expertise or equipment to patients before and/or during transport or
3- provide transport to patients otherwise inaccessible by other means of transport.
None of these criteria were present. Shortening the time to delivery of definitive care for this patient would have involved keeping her at the original admitting hospital or transferring her to another hospital in the same area. The patient did not have a time sensitive medical condition present. She required cardiac surgery but was clinically stable. She did not have cardiac surgery until four days after her transfer to the patient preferred hospital. In conclusion, the air ambulance transfer was not medically necessary.