Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic stage 4 retinoblastoma

Treatment: Fixed wing air transport (air ambulance) 

The insurer denied coverage for fixed wing air transport (air ambulance.) 

The denial is upheld.

The patient is a child with a history of metastatic stage 4 retinoblastoma, who has been under oncology care at a hospital close to home.  Recent imaging at the patient's treating facility showed evidence of spinal metastases and intracranial dissemination of disease. While visiting relatives in another part of the country, the patient developed worsening lower extremity weakness/plegia for one week and abdominal distension, with an inability to move their right arm, decreased urine output (UOP) and increased fussiness/altered mental status (AMS) for one day. The patient presented to the hospital out of state and received emergent palliative radiation therapy. The request is for fixed wing air transport (air ambulance) out of state where the patient is currently, back to home for continuity of care.

"Rotor-wing air ambulances received the greatest share of high-acuity patients (47.60%(percent)), followed by fixed-wing air ambulances (30.15%) and ground ambulances (3.85%). This trend was reversed for low-acuity patients: ground ambulances responded to the highest percentage of low-acuity patients (72.70%), followed by fixed-wing air ambulances (10.69%) and rotor-wing air ambulances (4.47%). These data suggest that air ambulances - both fixed-wing and rotor-wing - mostly respond to patients that providers determine to be medium-acuity or high-acuity, while a majority of calls ground ambulances respond to involve patients determined to be low-acuity. The fact that aeromedical emergency medical services (EMS) resources are predominantly being used for medium- and high-acuity patients is reassuring, because it suggests they are being effectively deployed." (Shekhar et al. 2021).

In determining the need for air transportation, Medicare guidelines are generally used. "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."

The issue is that the goal of transfer is unclear. Based on the web site, the current facility out of state is a highly developed, comprehensive oncology service. It is thus unclear what additional treatment would be gained by transfer to the patient's home facility. Note that the treating provider has been in contact with the patient's home facility. The records do not make clear what additional treatment would be provided at home that are not available out of state at the current facility.

Fixed wing air transport (air ambulance) is therefore not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for fixed wing air transport (air ambulance) is not substantiated.