Family Faces $97,000 Bill for Infant's Air-Ambulance Ride Denied by Insurer as 'Not Medically Necessary'

Cost of Critical Care

Amari Vaca, a 3-month-old baby who had undergone open-heart surgery, was flown from Salinas to San Francisco for specialized care due to respiratory syncytial virus (RSV). The air-ambulance flight covered an 86-mile distance and was operated by Reach Medical Holdings, part of Global Medical Response, an industry giant backed by private equity investors. The total bill for the air-ambulance service amounted to $97,599, which was not covered by the Cigna policy sponsored by his father's employer.

Insurer's Denial

Despite the enactment of the No Surprises Act in 2022, the family received a $97,000 "balance bill" from the air-ambulance provider because Cigna declined to cover any part of the bill. Cigna determined that the air-ambulance ride was not medically necessary, citing that other methods of transportation were feasible. The family disputed this decision, emphasizing that they simply followed the advice of the medical professionals involved.

Appeals and Challenges

Despite two appeals to Cigna, the insurer maintained its denial. The final step of the appeals process involves an external review, during which a third party evaluates the case. However, the hospital that arranged Amari's transport declined to write an appeal letter on his behalf, further complicating the situation for the family.

Public Response

The National Association of Emergency Medical Services Physicians noted a significant increase in claim denials based on "lack of medical necessity" following the enactment of the No Surprises Act. This situation has prompted calls for health plans to presume medical necessity for certain inter-facility air transports ordered by a physician at a hospital, subject to a retrospective review.

Seeking Resolution

Amid ongoing efforts to resolve the situation, the family expressed their disappointment and frustration with the denial from Cigna and the subsequent financial burden. Despite the challenges, they remain hopeful for a positive resolution to alleviate the substantial financial strain.

Patient Advocacy and Support

Healthcare experts encourage patients to persist in appealing bills that may seem inaccurate, emphasizing the potential for success through external reviews. Collaboration with medical providers and employer-sponsored health plans, as well as filing complaints with relevant authorities, are recommended avenues for patients to seek support in challenging insurance denials and inappropriate medical bills.

Conclusion

The case of Amari Vaca's air-ambulance bill highlights the complex challenges faced by families when navigating critical care and insurance coverage. As efforts continue to address the outstanding bill, the family and advocates stress the importance of patient advocacy and access to fair and equitable healthcare services, particularly in critical and emergency situations.