Transportation denials in California external review

What the reviewers wrote

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.

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