Air Ambulance Transport 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. The patient was involved in a bicycle accident on the date of service. He was reported to be riding unhelmeted when his front tire blew out and he was thrown from his bicycle. There was reportedly a witnessed loss of consciousness. Medics on the scene noted concern for a “soft spot” on the patient’s occipital region. There was a 3-inch laceration noted to the left parietal scalp and multiple abrasions including left hip, knee, elbow and arm. The patient was initially attended to by a ground ambulance crew, however air ambulance services were requested to transport the patient to the hospital. The patient’s vital signs in the field were stable and the patient had a Glasgow Coma Scale (GCS) score of 15 at the time of transport.

A 35-year-old female has requested coverage for past air ambulance transport services. Findings: The physician reviewer found that the patient is a gravida 4, para 0, Ab 3 female who was 32 and 2/7-weeks pregnant when her membranes ruptured and she began having episodic uterine contractions. She presented to the Emergency Department (ED) and was admitted for observation and fetal monitoring. The fetus’ heart rate did not become abnormal. She was consulted on and physical examination revealed that the patient was 80% effaced and 1-cm dilated. Laboratory tests confirmed that the vaginal fluid leak was amniotic fluid. She was also noted to have a culture-proven group B strep urinary tract infection (UTI). She was treated with penicillin for her UTI, Decadron to prevent lung disease associated with pre-term delivery, and terbutaline to inhibit additional contractions.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrolleehas requested reimbursement for medical transportation services provided Findings: The physician reviewer found that the enrollee who was residing in California when he was involved in an accident with a motor vehicle while riding a bicycle, The enrollee was transported to a local emergency room then transferred to a trauma center. The enrollee was diagnosed with a traumatic brain injury and underwent craniectomy. The enrollee sustained multiple soft tissue injuries, including abrasion and laceration injuries. The enrollee was transferred to a brain and spinal injury center for further care. The patient was in a comatose state and had a C2 vertebral body fracture requiring cervical collar and spinal precautions.

Nature of Statutory Criteria/Case Summary: A request for reimbursement was received for psychiatric emergency medical services per air ambulance that was provided from a medical center to an acute center for eating disorders. The Health Plan has denied the request indicating that the enrollee did not receive psychiatric emergency medical services. The records documented a history of hospital admission for diagnoses including anorexia nervosa, severe hypokalemia and severe protein malnutrition. The enrollee was transported from inpatient care for urgent impatient medical admission later. Documentation shows the patient’s severe protein malnutrition, refeeding syndrome, and Wernicke’s encephalopathy had resolved at the time transport was planned. The patient’s electrocardiogram (EKG) was normal and vital signs were stabilized.

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 Transport, then check the rights and deadlines that apply to your plan.