Air Ambulance Transportation denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested reimbursement for air ambulance transportation provided on 04/27/23.Central cord syndrome is an incomplete spinal cord injury often characterized by upper extremity dysfunction out of proportion with that of the lower extremities. The mechanism of injury is routinely a hyperextension injury in the setting of a traumatic event. There has been accumulating evidence regarding the role of surgery and its timing. In general, early surgery, often defined as occurring within 24 hours of an injury, is recommended to maximize neurological recovery. A review of the medical literature reveals the recommendation supporting early decompression for patients suffering from central cord syndrome.

Nature of Statutory Criteria/Case Summary: The patient’s parent has requested reimbursement for air ambulance transportation. Air ambulance transport involves the use of fixed-wing or rotary-wing aircraft to transfer a patient from one location to another. Generally accepted indications for air ambulance transport may be divided into medical and trauma categories. Medical indications include acute cardiac emergencies, acute surgical emergencies, acute neurological emergencies that require intervention, acute vascular emergencies, conditions that require hyperbaric oxygen, and critically ill patients requiring intensive care during transport. The list of trauma indications is rather long, but includes serious burns, hemodynamic instability, spinal cord injuries, multisystem injuries, penetrating trauma, limb-threatening injuries, near-drowning, and major pelvic fracture.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for air and associated ground ambulance transportation. At issue is whether the air and associated ground ambulance transportation rendered were medically necessary for the treatment of this patient.The records indicate that this patient was admitted to the hospital after presenting to the emergency department with altered mental status. The patient was found to be hypoxic and was diagnosed with metabolic encephalopathy with elevated liver function tests. Magnetic resonance imaging (MRI) findings were concerning for anoxic brain injury. The patient was discharged from the hospital and was transported via air and associated ground ambulance transportation to another facility for acute inpatient rehabilitation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air and ground ambulance transportation services.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. Traumatic brain injury, notably, is a major cause of disability in adults. While there is some natural recovery following acute traumatic brain injury, the impairments associated with this condition, nevertheless, are also generally amenable, at least in part, to various rehabilitation interventions. Formal rehabilitation in a setting that is appropriate for the patient’s level of dysfunction and clinical needs is the standard of care for this condition.In this case, the patient sustained a well-documented, severe, acute traumatic brain injury.

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