Issued and entered March 21, 2003 by Frances K. Wallace, Chief Deputy Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On August 28, 2002, XXXXXXXXXXX (“Petitioner”) filed a request for external review with the Commissioner of the Office of Financial and Insurance Services under the Patient’s Right to Independent Review Act (“PRIRA”), MCL 550.1901 et seq. After a review of the material submitted, the Commissioner accepted the request. Because a medical question is central to the proper resolution of the appeal, it was assigned to an independent review organization (“IRO”), as provided in section 11(6) of the PRIRA, MCL 550.1911(6). The IRO submitted its external medical review on October 3, 2002.

II
FACTUAL BACKGROUND

Petitioner is a Blue Cross Blue Shield of Michigan (“BCBSM”) member. He seeks coverage for his XXXXXXXXXX, air ambulance transportation from XXXX to Michigan. Petitioner was severely injured in a skiing accident in XXXX on XXXXXXXXXXXXXXXX. He broke both tibias, his left patella, and tore his left posterior cruciate ligament. Petitioner underwent surgery on XXXXXXXXXXXX, having intramedullary rods put into each tibia. His doctors in XXXX deemed him ready for transfer on XXXXXXXXXXXX, and an air ambulance transported him back to Michigan. After six days of intensive therapy in a Michigan hospital, his doctors there discharged him to home on XXXXXXXXXXXX. At that time he could transfer himself from wheelchair to car and from wheelchair to bed with minimal assistance. His doctors also allowed him 50% weight bearing on his left leg, and he could shower with his splints off.

BCBSM denied Petitioner coverage for the air ambulance service, because it concluded he should have delayed his return to Michigan until he was able to fly on a commercial airline. Petitioner believes the air ambulance service was medically necessary. Petitioner exhausted BCBSM’s internal grievance procedures, and BCBSM issued a final adverse determination in his case on August 9, 2002.

III
ISSUE

Is BCBSM required to pay for Petitioner’s XXXXXXXXXX, air ambulance service?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues BCBSM should cover his air ambulance service from XXXX to Michigan, because it was medically necessary given the severe nature of his injuries. He points out that during the trip he required the full immobilization of his lower extremities, intravenous fluids, continuous oxygen with pulse-oximetry monitoring, as well as frequent monitoring of his vital signs and mental status. Petitioner claims he would not have been able to utilize commercial air travel for least three months. He believes it would have been unreasonable for him to wait that long, as he needed to be with his wife and three school-aged children in Michigan. Petitioner therefore argues that the Commissioner should reverse BCBSM’s final adverse determination in his case.

BCBSM’S ARGUMENT

In its August 9, 2002, final adverse determination letter to Petitioner, BCBSM stated:

Based on our review, the documentation [Petitioner submitted] does not support the medical necessity of [his] transfer to a Michigan hospital. It is our consultants’ opinion that [he] could have completed [his] rehabilitation at a participating XXXX hospital until [he] could be transported by commercial airlines.

…One of the criteria [for coverage in Petitioner’s benefits contract] stipulates that air ambulance services are only payable when the patient is transported to the nearest facility capable of treating the patient’s condition. Since this was not the case, we must uphold our denial of payment.

IRO’S RECOMMENDATION

The medical expert who reviewed this case is board certified in physical medicine and rehabilitation. The reviewer determined that:

• Petitioner could have undergone his rehabilitation at the nearest appropriate facility in XXXX, which was only two miles away from the hospital where he had surgery;
• Petitioner could have flown to Michigan on a commercial airline after only five to six days of rehabilitation;
• Petitioner’s pain was under good control and was not an issue;
• Petitioner’s air ambulance transfer from XXXX to Michigan was for the convenience of his family and to increase his comfort;
• Petitioner’s air ambulance service was not medically necessary;

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents the parties submitted, as well as the findings of the IRO medical expert. The focus of this analysis is whether BCBSM properly denied Petitioner payment for his XXXXXXXXXXX, air ambulance service, according to the Community Blue Group Benefits Certificate that controls his coverage. The Certificate, in pertinent part, states:

Professional Ambulance Services
NOTE: When air ambulance service is required, it is payable if:

• the use of an air ambulance is medically necessary and ordered by attending physician
• no other means of transport is available, or the patient’s condition requires transport by air rather than ground ambulance
• the patient is transported to the nearest facility capable of treating the patient’s condition and
• the provider is licensed as an air ambulance service and is not a commercial airline

This language establishes four conditions which must be met for BCBSM to cover air ambulance services. One of these conditions is that air ambulance transport is medically necessary. Another condition is that the service is only to the closest facility that is appropriate for the patient. The IRO medical expert that reviewed this case found that Petitioner’s XXXXXXXXXX, air ambulance service did not meet either of these conditions.

The Commissioner accepts the findings of the IRO medical expert and concludes that Petitioner’s air ambulance transfer from XXXX to Michigan did not meet BCBSM’s conditions for coverage of that service.

IV
ORDER

BCBSM’s August 9, 2002, final adverse determination is upheld.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this order may seek judicial review no later than sixty days from the date of this order in the circuit court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.