Diagnosis: Respiratory System - COVID-19.
Treatment: Air Ambulance.
The insurer denied Air Ambulance.
The denial is upheld.

The patient is a male with hypertension (HTN), hyperlipidemia, coronary artery disease (CAD) with coronary artery bypass graft (CABG), ischemic cardiomyopathy with ejection fraction (EF) at 35-40%, and chronic kidney disease (CKD) III who presented with progressive weakness after having been admitted for coronavirus 2019 (COVID-19) pneumonia. He was treated with dexamethasone; remdesivir was withheld due to chronic kidney disease (CKD). After discharge, he went to his sister-in-law's house but returned with progressive weakness and shortness of breath (SOB) and was re-admitted.
During the second hospitalization, he was hypoxemic requiring high-flow nasal cannula and was treated for possible super-imposed bacterial pneumonia and ultimately finished 7 days of piperacillin-tazobactam, was restarted on dexamethasone for persistent hypoxemia; oxygen (O2) ultimately weaned down to 2 liters (L) and room air (RA) (still required 2L of O2 with exertion). He completed his 21 days of COVID-19 quarantine. His second hospitalization was notable for an elevated troponin suggesting a non-ST elevation myocardial infarction (NSTEMI). Cardiology was consulted and recommended medical management.
As he improved, it was felt after discharge he would need care in a transitional care unit (TCU). The patient had been hospitalized while visiting family in other state not his own state. He and his family requested transport to a TCU in his own state.

At issue is the medical necessity of Air Ambulance.

The health plan's determination of medical necessity is upheld in whole.

No, the requested health service/treatment of Air Ambulance was not medically necessary for this patient.

Transferring would have been for convenience. While it would be helpful for him to have his rehabilitation/TCU stay closer to family, there is no medical literature (including the studies submitted) that would show this is medically necessary or needed to recover. In these studies, functional independence is a major factor associated with successful discharge from rehab, but presence and engagement of family has not been a studied feature or one that has been noted to change outcomes.

Transferring to his own state for rehab would primarily have been for comfort and convenience as the exact same services could have been provided in his family's state. Having family nearby cannot be considered a medical necessity.

Therefore, the requested health service/treatment of Air Ambulance was not medically necessary for this patient.