Ninth Circuit Affirms Denial of Air Ambulance Transportation Claim for Lack of Medical Necessity

In Cont’l Med. Transp. LLC v. Health Care Serv. Corp., No. 21-35481, 2022 WL 2045385 (9th Cir. June 7, 2022), Plaintiff-Appellant Continental Medical Transport LLC, d/b/a Jet Rescue (“Jet Rescue”) brought suit under ERISA against The Boeing Company Consolidated Health and Welfare Benefit Plan (the “Plan”) and Health Care Service Corporation, d/b/a Blue Cross Blue Shield of Illinois (“Blue Cross”) for denying payment for patient “D.O.”’s air transport from Lima, Peru to Miami, Florida as not medically necessary under the Plan. The district court granted summary judgment to Defendants and Jet Rescue appealed. The Ninth Circuit affirmed, with a dissent by Senior Circuit Judge Bea.

First, the court found that the district court correctly applied an abuse of discretion review standard because the Plan administrator, comprised of a committee, voted to approve Blue Cross as Plan Administrator and this vote was subsequently ratified by Plan documents showing an unequivocal delegation of discretion to Blue Cross. Second, under either an abuse of discretion or de novo standard, the court found that “the district court’s conclusion that D.O’s air transport from Lima to Miami was not medically necessary under the Plan was overwhelmingly supported by the record.” A patient must meet certain requirements for air transportation to be deemed medically necessary. D.O. did not meet the requirements. The court found that there was no evidence that D.O. could not have received certain care and treatment at the hospital in Lima and that the hospitals’ plan of care was similar. Lastly, the court found that the independent review organization’s (“IRO”) denial of benefits does not require de novo review because “the IRO’s non-binding affirmance of Blue Cross’s denial of benefits did not negate Blue Cross’s discretion.”

In Judge Bea’s dissent, he argued that the Plan did not properly delegate fiduciary responsibility under the terms of the Plan to Blue Cross so de novo review should apply. He also argued that summary judgment to Blue Cross was not appropriate because there are genuine disputes as to material facts surrounding whether D.O.’s air transport was medically necessary.