Appeal type: Transportation
Decision: Partially Favorable

 We decided that the Plan has to pay for the air ambulance transportation at the ground ambulance rate. We decided that the Plan does not have to pay in full for the air ambulance transportation.   You asked the Plan to pay for the air ambulance transportation. The Plan says that the information provided at the time of the appeal does not support criteria for air ambulance transport.  We decided that the Plan has to pay for the air ambulance transportation at the ground ambulance rate.   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 for the air ambulance transportation. Our reviewer says that the documentation does support that the patient suffers from an illness or injury that contraindicates transportation by any means other than ambulance. The patient was unsafe to drive closer to network to receive services. Our reviewer also found that the documentation does support that the transferring hospital did not have adequate facilities to provide the medical services needed by the patient. They did not have spinal care available.  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 transportation have been met. Therefore, we decided that the Plan has to pay for the air ambulance transportation at the ground ambulance rate.   We also decided that the Plan does not have to pay in full for the air ambulance transportation.  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 for the air ambulance transportation. Our reviewer says that the documentation does not support that the patient's condition was such that the time needed to transport a patient by ground, or the instability of transportation by ground, posed a threat to the patient's survival or seriously endangered the patient's health. Our reviewer also found that the patient was stable, did not have cauda equina, did not need urgent surgery, was able to ambulate.  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 transportation have not been met. Therefore, we decided that the Plan does not have to pay in full for the air ambulance transportation.  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.