Non Emerg Med (NEMT) denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for (1) center-based applied behavior analysis (ABA) therapy consisting of 15 hours per week 2:1 (30 hours total) and 255 hours of enhanced supervision over a sixth month period and (2) two technicians to be present during the patient’s non-emergency medical transportation (NEMT) services to and from the services. Findings: The physician reviewer found that the patient displayed significant aggressive behaviors during behavioral assessments that occurred by telehealth in the patient’s home, tackling caregivers to the ground and having to be barricaded the basement due to the intensity of his behaviors. During an in-person assessment in the car, the patient was noted as being aggressive during the transportation, engaging in high-intensity biting, choking, and hitting.

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for non-emergency psychiatric transportation to and from applied behavior analysis therapy. Findings: The physician reviewer found that patient centered care (PCC) has been defined as, “Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.” Patient- and family-centered care interventions are increasingly being implemented in various settings for improving the quality of health care.

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.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for non-emergency air, and associated ground ambulance, transportation services. At issue is whether the non-emergency air, and associated ground ambulance, transportation services 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 intracranial hemorrhage and fractures to the right femur, first rib, T1 transverse, and clavicle due to a motor vehicle accident. The patient required placement of a ventriculostomy and then a left decompressive hemicraniectomy as well as intramedullary nail fixation of the right femur.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Non Emerg Med (NEMT)when you appeal: reviewers routinely find that denials like yours didn’t hold up.