A mom's $97,000 question: How was her baby's air-ambulance ride not medically necessary?

Service Provider: Reach Medical Holdings, which is part of Global Medical Response, an industry giant backed by private equity investors. Global Medical Response operates in all 50 states and has said it has a total of 498 helicopters and airplanes. It is out-of-network with Amari’s Cigna plan.

Total Bill: $97,599. Cigna declined to cover any part of the bill.

What Gives: Legal safeguards are in place to protect patients from big bills for some out-of-network care, including air-ambulance rides.

Medical billing experts said the No Surprises Act, a federal law enacted in 2022, could have protected Amari’s family from receiving the $97,000 “balance bill,” leaving the insurer and the air-ambulance provider to determine fair payment according to the law. But the protections apply only to care that health plans determine is “medically necessary” — and insurers get to define what that means in each case.

According to its coverage denial letter, Cigna determined that Amari’s air-ambulance ride was not medically necessary. The insurer cited its reasoning: He could have taken a ground ambulance instead of a plane to cover the nearly 100 roadway miles between Salinas and San Francisco.

“I thought there must have been a mistake,” England said. “There’s no way we can pay this. Is this a real thing?”

In the letter, Cigna said Amari’s records did not show that other methods of transportation were “medically contraindicated or not feasible.” The health plan also noted the absence of documentation that he could not be reached by a ground ambulance for pickup or that a ground ambulance would be unfeasible because of “great distances or other obstacles.”

Lastly, it said records did not show a ground ambulance “would impede timely and appropriate medical care.”

When KFF Health News asked Cigna what records were referenced when making this decision, a spokesperson declined to respond.

Caitlin Donovan, a spokesperson for the National Patient Advocate Foundation, said that even though Amari’s bill isn’t technically in violation of the No Surprises Act, the situation is exactly what the law was designed to avoid.

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