Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower Extremity Injuries 
Treatment: Healthcare Common Procedure Coding System (HCPCS) code A0426 [A0426 ambulance service, advanced life support [ALS], non-emergency transport, level 1, (ALS 1)] x 2, HCPCS code A0430 [ambulance service, conventional air services, transport, one way (fixed wings)], HCPCS code A0434 [specialty care transport (SCT)], and HCPCS code A0435 [fixed wing air mileage, per statute mile] x 1,121

The insurer denied coverage for Healthcare Common Procedure Coding System (HCPCS) code A0426 [A0426 ambulance service, advanced life support, non-emergency transport, level 1, (ALS 1)] x 2, HCPCS code A0430 [ambulance service, conventional air services, transport, one way (fixed wings)], HCPCS code A0434 [specialty care transport (SCT)], and HCPCS code A0435 [fixed wing air mileage, per statute mile] x 1,121.
The denial is upheld.

This patient with a history of hypertension, degenerative joint disease (DJD), suffered lower extremity injuries related to a vehicular accident. After the injury, the patient was admitted to a rehabilitation hospital for intensive and comprehensive rehabilitation. During the admission, the patient underwent multiple incision and drainage (I&D) procedures and skin grafts. She was seen by physical and occupational therapy (PT and OT). Approximately a month later, the patient was transported by air ambulance from the rehabilitation hospital to a nursing center to be closer to her home. 

As noted in nationally accepted Centers for Medicaid and Medicare (CMS) Guidelines:

"...Hospital to Hospital Transport ...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. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A 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."

"...Special Coverage Rule...Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician's office, or a beneficiary's home."

The medical record demonstrates transport was to allow treatment at a facility closer to home. The service would be for "convenience". There were no additional nor different medical services provided. There was no reason why additional treatment could not have been continued in Florida at the rehabilitation facility. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Healthcare Common Procedure Coding System (HCPCS) code A0426 [A0426 ambulance service, advanced life support, non-emergency transport, level 1, (ALS 1)] x 2, HCPCS code A0430 [ambulance service, conventional air services, transport, one way (fixed wings)], HCPCS code A0434 [specialty care transport (SCT)], and HCPCS code A0435 [fixed wing air mileage, per statute mile] x 1,121 is upheld. Medical Necessity is not substantiated.