Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for the transport code and mileage code up to the mileage to the nearest 
facility in San Juan. We decided that the Plan does not have to pay for the transport code and mileage code up 
to the mileage to the facility in Miami. 
 
You asked the Plan to pay for air ambulance transportation services provided on October 8, 2022.. You say that 
the services provided were medically necessary. The Plan says that there is no documentation in the clinical 
record documenting any reason required services were not available or could not be utilized to treat the 
enrollee's medical condition at the closer trauma hospital in Puerto Rico. 
 
We decided that the Plan has to pay for the transport code and mileage code up to the mileage to the 
nearest facility in San Juan. 
 
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 services. 
Our reviewer says that the criteria for coverage of air ambulance transport to San Juan was met. Our physician 
reviewer found that transfer from the facility in St. Thomas was medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transportation services to San Juan have been met. Therefore, we 
decided that the Plan has to pay for the transport code and mileage code up to the mileage to the nearest facility 
in San Juan. 
 
We also decided that the Plan does not have to pay for the transport code and mileage code up to the 
mileage to the facility in Miami. 
 
The Plan follows Medicare rules. Medicare rules say that they will pay for ambulance services that meet certain 
origin and destination requirements. Medicare will cover ambulance transportation services from any point of 
origin to the nearest hospital capable of furnishing appropriate care for a patients illness or injury. 
 
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 services. 
Our reviewer says that the criteria for coverage of air ambulance transport to Miami was not met. Our 
physician reviewer found that it is unclear why the enrollee was not transported to San Juan, Puerto Ricos 
trauma hospital. There is no documentation that the required services were not available in San Juan and that 
transport to the further facility was required.  
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of air ambulance transportation services to Miami have not been met. Therefore, 
we decided that the Plan does not have to pay for the transport code and mileage code up to the mileage to the 
facility in Miami provided on October 8, 2022. 
 
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.