Diagnosis: Right total knee arthroplasty
Treatment: Ambulance Services
The insurer denied Ambulance Services
The determination is upheld.

This is a female patient diagnosed with right knee arthritis. There is a request regarding ground ambulance transportation. An operative note from the physician documents that the patient underwent a right total knee arthroplasty. There is a nonemergent transport certification form stating that the patient required transportation as the patient was on continuous oxygen which cannot be self-administered as the patient has an illness preventing them from being able to self-administer oxygen, is unable to get up from a bed without assistance, and unable to sit safely in a chair or wheelchair. The patient has comorbid diabetes, obstructive sleep apnea, and cardiac history. A prior review indicates that the patient was transported from a hospital to a skilled nursing facility. A transport record indicated that the patient was alert and oriented, her vital signs were within normal limits, and she was on four liters of oxygen via nasal cannula. The patient was assisted out of the chair, able to stand and sit on a stretcher without incident, the vital signs were reviewed and normal during transportation, no incidents were reported, and the patient was brought to the room on a stretcher and transferred to a hospital bed upon arrival without incident. An appeal letter from the patient states that after a knee replacement surgery, the patient required a skilled nursing facility for recovery. The patient stated the need for oxygen following surgery above normal usage prior to surgery. At issue is the medical necessity of ambulance services.

The ambulance transportation was not medically necessary. The plan supports ambulance transportation services which are due to an emergency or in nonemergent cases based on medical necessity. In this circumstance, there was no documentation of an emergent condition that required it to be transportation. Additionally, there is no documentation that the care provided was most appropriate level of service or supply which can safely be provided. The documentation provided indicates that the patient utilizes oxygen prior to surgery and there is no indication the patient could not continue to self-administer oxygen or that the patient could have safely been transferred upright as the patient was able to sit safely in a chair and wheelchair.