Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services. The patient was involved in a bicycle accident on the date of service. He was reported to be riding unhelmeted when his front tire blew out and he was thrown from his bicycle. There was reportedly a witnessed loss of consciousness. Medics on the scene noted concern for a soft spot on the patients occipital region. There was a 3-inch laceration noted to the left parietal scalp and multiple abrasions including left hip, knee, elbow and arm. The patient was initially attended to by a ground ambulance crew, however air ambulance services were requested to transport the patient to the hospital. The patients vital signs in the field were stable and the patient had a Glasgow Coma Scale (GCS) score of 15 at the time of transport. He was transported to a medical center for treatment, were he was cared for by the trauma service. The patients work-up did not reveal any injuries requiring treatment beyond repair of his scalp laceration, and he was discharged the following day. The health plan has denied coverage of the air ambulance services indicating that they are not emergency medical services.California Health and Safety Code  1317.1, subdivision (a)(1), defines emergency services and care as medical screening, examination, and evaluation by a physician and surgeon, or, to the extent permitted by applicable law, by other appropriate licensed persons under the supervision of a physician and surgeon, to determine if an emergency medical condition or active labor exists and, if it does, the care, treatment, and surgery, if within the scope of that person's license, necessary to relieve or eliminate the emergency medical condition, within the capability of the facility. California law defines an emergency medical condition as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy, serious impairment to bodily functions and/or serious dysfunction of any bodily organ or part.The submitted documentation supports that the services at issue were emergency medical services. The patients medical records documented serious acute injuries, dysfunction, and jeopardy to the patients health, with documentation of the EMS crews attending to the patient with a witnessed loss of consciousness after suffering an unhelmeted fall from his bicycle. The patient also had a large laceration across his parietal scalp and a questionable soft spot to his occipital region. The EMS crew documented concern for a possible skull fracture. Emergent transfer for a rapid trauma evaluation was required and the field determination was that this would be best achieved via air transport. Under these circumstances, the absence of immediate medical attention could reasonably have been expected to result in placing the patients health in serious jeopardy, and the patient therefore had an emergency medical condition that required screening by a physician to determine the care, treatment, or surgery necessary to relieve or eliminate the emergency medical condition. Therefore, air ambulance services were emergency medical services as defined by California law.Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.