Air Ambulance denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services.Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or when there is a great distance or obstacle involved in land transport. Another circumstance would be when the time needed to transport the patient by land poses a threat to a patient’s survival or the proper equipment needed for the patient is not available on a land ambulance. A patient might also require air ambulance services in order to be transferred from one institution to another in order to receive specialized services such as trauma care or a burn unit.

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance service. Researchers explain that basilar artery thrombosis is a devastating form of stroke with high morbidity and mortality, with mortality rates greater than 85% that drop to 40% with recanalization. While survival after stroke depends initially on the acute phase of specialist hospital care, optimal recovery requires the provision of coordinated specialist rehabilitation, not only in the early stages but usually months after the stroke. The location of such a rehabilitation facility close to the patient’s home and family, where family members’ participation can provide psychological stability and serve as motivation for progress toward recovery, and where family members can easily partake in the decision-making process, is vital to ensuring good outcomes for patients.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air ambulance services provided by Critical Care Medflight. Functional impairments due to traumatically acquired brain insults can be profound, particularly in the setting of severe injuries and in the setting of intracerebral hemorrhage. Eapen and colleagues note that traumatic brain injury (TBI) sequelae can lead to long-term impairments in physical, cognitive, behavioral, and social function. Per the authors, TBI rehabilitation requires an interdisciplinary holistic team approach in the management of medical complications, the prevention of further disability, and helping patients return to their highest level of independence. While there is some natural recovery following acute TBI, the impairments associated with this condition are also generally amenable to various rehabilitation interventions.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for air ambulance service provided on 12/27/17. The Health Plan has denied this request indicating that the requested service was not medically necessary for treatment of the enrollees epilepsy.At issue in this case is whether the requested air ambulance service was medically necessary for treatment of the enrollees medical condition.In most cases, air ambulance transport is reserved for use in emergent situations in which ground transport is not feasible or readily available. Such situations from the neurology perspective include (but are not limited to), intracranial hemorrhages, strokes requiring endovascular therapy or other conditions requiring acute surgical intervention.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Air Ambulance, then check the rights and deadlines that apply to your plan.