Diagnosis: s/p Eye injury
Treatment: Air ambulance
The insurer denied Air ambulance.
The denial is overturned.

The patient is a teen-aged. She presented to the ED after having been hit in the left eye at close range by a kicked soccer ball. She had no loss of consciousness, vomiting, or headache, but she had blurry vision and left periorbital pain rated 5/10. She was initially taken by private auto to another ED and found to have irregular pupil with grade 1 hyphema.

An orbital CT scan was negative. Visual acuity tested 20/25 in the right eye and 20/40 in the left eye. Although the blurriness was improving, eyelid swelling was getting worse. She was transferred to another ED via air transport for higher level of care.

The patient's vital signs included temperature 36.8, heart rate 63, respiratory rate 18, and blood pressure 116/71. Examination was significant for no distress, left periorbital swelling with tenderness to palpation, conjunctival redness with tiny hyphema, extraocular movements intact, left pupil ovoid/irregular, and non-focal neurologic exam. She was diagnosed with tiny hyphema, likely traumatic iritis. Pediatric Ophthalmology was consulted, diagnosing traumatic hyphema and retinal commotion. She was prescribed Pred Forte drops, cyclopentolate drops, recommendations to sleep upright, and recommendations to follow-up in three days.

This teenage female presented to the ED after a traumatic injury to her left eye. She initially was driven to the ED where she was evaluated and noted to have left hyphema with irregularly shaped pupil. After completing a physical examination and obtaining a CT scan, the decision was made to transfer her to higher level of care. One of the concerns with anterior chamber bleeding with hyphema formation is increased intra-ocular pressure. Without the proper tools, the first ED was not able to fully evaluate her. She would undergo further evaluation in the Pediatric ED by both the ED team and Pediatric Ophthalmology.

The acute development of increased intra-ocular pressure presents an urgent/emergent situation. In the absence of proper tools and consultants at the first ED, with intact vision at risk, unnecessarily wasted time serves only to exacerbate the situation. The distance between the first hospital and the destination hospital based on a standard map site is about 30 miles, representing three quarters of an hour transport time without any traffic or detours by land. With a potential ocular emergency, ground transportation represented an unnecessary and unacceptable waste of time. Air transport was medically necessary and appropriate in this case.