Emergency 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.

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: 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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for transporting the enrollee back to the United States.Findings: Air ambulance is considered medically necessary under certain circumstances. These circumstances can include when the point of pickup is inaccessible by land or 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.

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