--- ## Page 1 Angel MedFlight Worldwide Air Ambulance Services attn. John W. Shamblin, Esq 15990 N. Greenway-Hayden Loop Suite C120 Scottsdale, Arizona 85260 J. Jongsma 851 Brightwaters Blvd NE St. Petersburg, FL 33704 St. Petersburg, March 9ᵗʰ, 2023 Appeal for Sophia Helena Jongsma Dear Mr. Shamblin, We recently received a letter and Authorization for Release of Confidential Information for Appeal review from Cigna Appeals, which mentioned your name. We are glad to hear that you are involved in our case. Enclosed, you will find a copy of the documents we previously submitted to Cigna for your convenience. If you need any further information or documentation, please do not hesitate to contact us at 727-225-2475. We are available at your convenience and would be grateful to resolve this issue as soon as possible, as it involves a significant amount of money. Thank you for your time and attention. We look forward to hearing back from you soon. Best regards, Johan Jongsma email: johan@jongsma.me phone: +1 727 225 2475 --- ## Page 2 Cigna Appeals PO Box 188062 Chattanooga, TN 37422 J. Jongsma 851 Brightwaters Blvd NE St. Petersburg, FL 33704 St. Petersburg, March 9ᵗʰ, 2023 **ID# 107120746** **SR# 1457315794** To whom it may concern, I send you hereby the signed Authorization for Release of Confidential Information for Appeal Review and a letter written by Dr. F.F. Nievas M.D., dated June 28ᵗʰ, 2022. This letter clearly states the necessity of our daughter Sophia Helena to be transported by air ambulance to the Kennedy Krieger Institute in Baltimore, MD. It was essential for Sophia's recovery to be treated in a rehab clinic. Given the complexity of Sophia's case (pediatric and both Anoxic Brain Injury and Ventilator dependent) Sophia was rejected by multiple centers, such as Houston, Jacksonville and Atlanta, so, we were happy that Sophia was accepted by KKI. As a result of the limited time available to secure Sophia's admission, we agreed to prepay the air ambulance transportation to KKI, confident that this would be covered by our insurance. It is important to note that the return flight (from Baltimore to St. Petersburg) in September was approved after a phone call between Dr. Melicosta (KKI) and a doctor from Cigna. If you require any further information or documentation, please do not hesitate to contact us. We are available at your convenience and would be more than happy to discuss this matter further. Thank you for your time and attention. We look forward to hearing back from you soon. Best regards, Johan Jongsma | email: johan@jongsma.me | | phone: +1 727 225 2475 | --- ## Page 3 JOHNS HOPKINS MEDICINE | JOHNS HOPKINS ALL CHILDREN'S HOSPITAL ## LETTER OF MEDICAL NECESSITY June 28, 2022 Re: Sophia Jongsma DOB: 1/1/2017 To: Reviewing Medical Director This letter is in support of the medical necessity of air ambulance transportation for patient, Sophia Jongsma, from Johns Hopkins All Children's Hospital in St. Petersburg, Florida to Kennedy Krieger Institute in Baltimore, Maryland to receive specialized neurological rehabilitation. Sophia suffers from acute hypoxic ischemic encephalopathy secondary to a cardiac arrest and crush injury involving an elevator shaft. Sophia is a previously healthy 5-year-old with no significant past medical history. She was reportedly at home with family when involved in an elevator accident at her home. She was found in the elevator shaft which was up from the doorway with Sophia's head and upper body inside the elevator, while trapped at the waist between the shaft and elevator with her feet dangling down. Her parents were not successful in getting her out. EMS was called to rescue her. Upon their arrival, EMS needed equipment from outside resources to extricate Sophia. Once the resources became available and extricated, Sophia was found to be in cardiac arrest which necessitated PALS protocol. Attempts to intubate were unsuccessful and there was vomitus on the floor and on Sophia. Sophia was transported to Johns Hopkins All Children's Hospital with resuscitation efforts while in route. Upon hospital arrival, her Glasgow Coma Scale was 3 and she was pulseless and apneic. She was successfully intubated in the ER. Two doses of epinephrine and a normal saline bolus were administered with return of spontaneous circulation. Further evaluation revealed good carotid and femoral pulses, abrasions across her abdomen and upper right thigh, compression bruises to her buttocks, and no neurological response. Sophia is now with acute hypoxic ischemic encephalopathy secondary to cardiac arrest and crush injury. A tracheostomy was placed for acute respiratory failure along with a chest tube for left pneumothorax which was subsequently removed. Additonal problems include seizures, autonomic dysfunction, hyponatremia, and acute liver injury. Sophia is on trach trials during the day with CPAP if not tolerated, and ventilator at night. Her eyes are partially open with pupils dilated bilaterally, and sluggish to react to light. She remains non-interactive with no spontaneous movement to painful stimuli. Rigid, hypertonic extremities display with intermittent contractile movements with no purpose. Prior to her accident, Sophia was playful with all activities. As a result of her accident, she suffers from neurological deficits. A decision is accordingly made to transfer her to a facility that can provide aggressive neurological rehabilitation. She is therefore referred to and accepted into Kennedy Krieger, the most appropriate accepting facility to meet her needs. Brain injury victims --- ## Page 4 may need extensive rehabilitation to restore lost brain functions or to learn how to compensate for functions that cannot be restored. Recovery is influenced by classes of factors such as individual patient characteristics, social-environmental factors (e.g., family support), and barriers to rehabilitation access. Following hospitalization for brain injury, persons can receive rehabilitation care and services in various settings. Post-acute rehabilitation is provided and is typically indicated when the medical condition requires continued skilled nursing care. Individual characteristics such as age and pre-injury functioning can influence outcomes from brain injury. Social-environmental factors (e.g., socioeconomic status, social support, caregiver and family functioning) also can influence outcomes after traumatic brain injury.¹ Benefits of treatment at Kennedy Krieger include high-quality staff with focused experience, peer support from patients with similar injuries, specialized patient and family education and resources, more options to participate in research studies, access to services not found in most rehabilitation centers, and specialized long-term support. Kennedy Krieger Institute is a world premier institution dedicated to improving the lives of children with disorders of the brain through patient care, special education, research, and professional training. Their individualized approach to treatment is the most appropriate approach for Sophia's continued care.² At the time of transport, Sophia will not be an appropriate candidate for commercial air travel due to her need for hemodynamic management, respiratory assessment/management, neurological injury assessment and safety measures.³ To prevent further deterioration of her condition that potentially poses a threat to her life and vital organ function, ICU level monitoring is needed during transport. Sophia requires complete assistance with all transfers and positioning. Ground transport is medically contraindicated as the excessive distance of 960 miles/15.5 hours places her out of range of emergency medical care in the event of deterioration while in transit.⁴ I therefore request approval of this medically necessary air ambulance transport for Sophia to Kennedy Krieger Institute. Sincerely, [signature] Federico Fernandez Nievas M.D. --- ¹ Traumatic Brain Injury in the United States: Epidemiology and Rehabilitation. U.S. Dept. of Health and Human Services. ² www.kennedykrieger.org. ³ Aerospace Medical Association Medical Guidelines Task Force (2003). Medical guidelines for airline travel (2^nd edition). Aviation, Space and Environmental Medicine 74 (5). ⁴ Medicare Benefit Policy Manual Chapter 10 § 10.4.3. 2 --- ## Page 5 # Authorization for Release of Confidential Information for Appeal Review **Member ID#** 107 120 746 **SR#** 145 731 5794 **I,** Johan Tongoma 851 Brightwaters Blvd NE St Petersburg, FL (Name) (Address) **Authorize,** John W. Shamblin Esq (Name) **To disclose to:** Cigna Appeals PO Box 188062 Chattanooga TN (Name) (Address) **The following information:** All information about my daughter Sophia Helena Tongoma (1-1-2017) relevant for the appeal case **For the following purpose:** To demonstrate that Sophia's transport to the Kennedy Krieger was neccesary for her recovery and was the only available option. ## A COPY OF THIS RELEASE IS AS VALID AS AN ORIGINAL This Authorization may be withdrawn at any time in writing except to the extent that the program or person, which is to make this disclosure, has acted in reliance on it. Upon revocation of authorization, further release of information shall cease immediately. This release of information expires in 365 days following completion or termination of treatment, except for information to be released or exchanged for purposes of a claim for benefits. If for a claim for benefits, this release of information expires upon termination of coverage under the insurance policy or benefit plan or the final determination of the claim, if later. Executed this **9th** day of **March** , year **2023** _______________________________ _______________________________ (Participant) (Parent, Guardian, Authorized Representative, if required) If participant is unable to give consent because of physical condition or age, complete the following: Patient is a minor **6** years of age or is unable to give consent, because _______________ ## A COPY OF THIS EXECUTED RELEASE SERVES THE SAME PURPOSE AS AN ORIGINAL ### TO THE RECIPIENT OF CONFIDENTIAL INFORMATION If the information disclosed to you relates to substance abuse treatment, these records' confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient to release substance abuse records. The Federal Rules restrict any use of the information to criminally investigate or prosecute any substance abuse patient. State laws may also protect the confidentiality of patient's records. *Please return completed form to:* **National Appeals Organization** **Attn: Appeals** **P O Box 188062** **Chattanooga, TN 37422** --- ## Page 6 Cigna Appeals PO Box 188062 Chattanooga, TN 37422 February 20, 2023 Tatyana Busel Jongsma 851 Brightwaters Blvd NE Saint Petersburg FL 33704-3719 RE: Cigna Health Management, Inc. on behalf of Cigna Health and Life Insurance Company Name: Sophia Jongsma ID #: 107120746 Dates of Service: 06/28/2022 SR #: 1457315794 Dear Tatyana, On January 5, 2023, we received an appeal request from John W. Shamblin, Esq. concerning our decision to deny coverage for the services referenced in this request for the above dates. **What Happens Next** To process your appeal, we will need you to sign and return the enclosed "Authorization for Release of Confidential Information for Appeal Review" form. We will not be able to complete our review of your appeal until we receive the signed Authorization Form. If you need to make any changes or submit any additional documentation, please include that information when you return the signed Authorization Form. We consider your request an "appeal". Once I receive all of your required information, I'll give it to one of our physician reviewers or designees to review it. The physician reviewer or designee performing this review wasn't involved in the original review. They're looking at your request as an unbiased reviewer. Then, within thirty (30) calendar days from the date we receive your signed Authorization Form, we'll send you a letter with our updated coverage decision. We'll also let you know in writing if we need more time to gather information. If we don't make the appeal decision within the required or agreed timeline, the initial adverse determination will automatically be reversed. All Cigna products and services are provided exclusively by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Evernorth Behavioral Health, Inc., Evernorth Care Solutions, Inc., Evernorth Direct Health, LLC, Cigna Health Management, Inc., subsidiaries of eviCore 1, LLC and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. Please refer to your ID card for the subsidiary that insures or administers your benefit plan. Cigna Health Management Inc. and Evernorth Behavioral Health, Inc., Evernorth Care Solutions, Inc., Evernorth Direct Health, LLC, Inc. are licensed or certified utilization review entities. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

Cigna Appeal Letter Sophia Helena Jongsma

Details

Summary

Notes

OCR Text

Document Preview

Share Document

Active Shares

Edit Document