Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p Motorcycle Accident. 
Treatment: Air and Ground Ambulance Transportation (A0430,A0434,A0426,A0435). 

The insurer denied the Air and Ground Ambulance Transportation (A0430,A0434,A0426,A0435). 

The denial is overturned.

The patient is a male with history of Motor Cycle Accident, having sustained multiple traumatic injuries including spinal injuries and Traumatic Brain injury, with initial Glasgow Coma Scale of 3. 

The patient was found to have sustained splenic injury status post laparotomy and splenectomy, pancreatic injury, fractured 12 ribs, Right frontal cerebral contusion, right subarachnoid hemorrhage, Right subdural hematoma, Left C7 (seventh cervical spine vertebra), T1 (first thoracic spine vertebra), T2 (second thoracic spine vertebra) and L2 (second lumbar spine vertebra) transverse process fractures, Left open Tibia/fibula fracture, Right wrist dislocation, status post PEG (percutaneous endoscopic gastrostomy) tube, status post tracheostomy, etc, and multiple surgical interventions. 

The patient was in acute rehabilitation in another state, and air and ground ambulance was requested to transport him to a facility closer to his home and family support in his home state, a flight distance of more than 2,100 miles. 

Yes, the Air and Ground Ambulance Transportation (A0430,A0434,A0426,A0435) 07/18/2020 was medically necessary. 

This is an hospital to hospital ambulance transportation of a patient who after a Motor Cycle Accident sustained splenic injury status post laparotomy and splenectomy, pancreatic injury, fractured 12 ribs, Right frontal cerebral contusion, right subarachnoid hemorrhage, Right subdural hematoma, Left C7 (seventh cervical spine vertebra), T1 (first thoracic spine vertebra), T2 (second thoracic spine vertebra) and L2 (second lumbar spine vertebra) transverse process fractures, Left open Tibia/fibula fracture, Right wrist dislocation, status post PEG (percutaneous endoscopic gastrostomy) tube, status post tracheostomy, etc, and multiple surgical interventions. His medical management team decided to transfer him to his home state, which is more than 2,100 miles away for continued medical care and Traumatic Brain Injury Rehabilitation closer to his family, support system and power of attorney, where he lives. 

The need for such level of family and other support system is essential due to need for prolonged rehabilitation and also due to the nature of his injuries, especially related to the Traumatic Brain Injury. 

Because the patient had multiple injuries as stated above that will require prolonged period of rehabilitation, it was medically necessary and reasonable for him to be transported by air ambulance over a distance of more than 2,100 miles closer to his support system, as any other form of transportation would be inappropriate and not safe for the patient, and from the arrival airport to his final hospital destination by ground ambulance for the remaining distance. 

The patient continues to need PT (physical therapy), OT (occupational therapy) and SLP (speech and language pathology) rehabilitation. 

The need for such level of family and other support system is essential due to need for prolonged rehabilitation and also due to the nature of his injuries, especially related to the Traumatic Brain Injury. 

Any other form of ambulance transportation or commercial transportation outside the air ambulance transportation over a distance of more than 2,100 miles with his medical condition could not have been beneficial to the patient.