Appeal type: Transportation
Decision: Partially Favorable

 We decided that the Plan has to pay for the ambulance services at the rate of an air transport from the pick-up point to the nearest hospital. We decided that the Plan does not have to pay for any additional amount beyond the air transport from the pick-up point to the nearest facility.   You asked the Plan to pay for the ambulance services. You say that you were on vacation with your family when you had an emergency and needed to go to the hospital. You say that you were advised you needed to go to a bigger hospital for care. You say that there was no ground ambulance available, only air ambulance. You also say that your policy says ambulance services are covered. The Plan denied your request. The Plan says you were not transported to the nearest facility.  We decided that the Plan has to pay for the ambulance services at the rate of an air transport from the pick-up point to the nearest hospital.   The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay an additional amount for the transportation services. Our reviewer says that the air ambulance transportation was medically necessary. Our physician reviewer found the provided documentation supports that you had a medical condition that contraindicated transportation by any means other than ambulance. The reviewer found that no ground emergency medical service (EMS) was available, and therefore it is determined that this precluded rapid transport by ground to a treatment facility. The reviewer found that transport by air ambulance was medically reasonable and necessary in this case. The transferring hospital was a critical access hospital, which is a small facility that gives limited outpatient and inpatient services to people in rural areas.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the air ambulance services to the nearest facility at the rate have been met. Specifically, the file shows that there was no ground ambulance available at the time. Therefore, we decided that the Plan has to pay for the transportation services at the rate of an air transport from the pick-up point to the nearest hospital.  We also decided that the Plan does not have to pay for any additional amount beyond the air transport from the pick-up point to the nearest facility.  The Plan follows Medicare rules. The rules say that only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered.  Our physician reviewer also found that the documentation does not support that you were delivered to the nearest appropriate facility. Therefore, the air transport payment is limited to the rate for the distance from the point of pick-up to the nearer hospital.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the transportation services have not been met. The file shows that the facility you were transported to was 91 miles away. The file also shows there was an appropriate facility located 57 miles from the pick-up point. Therefore, we decided that the Plan does not have to pay any additional amount beyond the air transport from the pick-up point to the nearest facility.  If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.