Insurance company denied payment for life-saving air ambulance, claiming unconscious patient failed to get preapproval

HANOVER, Ind — Amanda Boley says Oct. 24, 2024 started like a normal day.

 She went to work. She walked her dog, Maya, when she returned home. She sat in her living room to text a co-worker.

 Boley doesn’t remember much after that.

“My dog was acting a little weird and I looked at her and said, ‘What do you want?’ and I kinda played with her a little bit,” she recalled during an interview with 13News. “And then I was gone.”

Gone, as in clinically dead.

Just after 6:00 p.m., Boley collapsed in the living room of her Hanover home. A family member heard the dog barking wildly and found Boley unconscious. Following a frantic call to the Jefferson County 911 Dispatch Center, Hanover Police Sgt. Kyle Pence arrived a few minutes later.

“She was not conscious, not breathing … I did not feel a pulse while I was there,” said Pence, who deployed an AED and performed CPR on Boley until paramedics arrived.

Video from a doorbell camera shows those paramedics wheel Boley into an ambulance while her family pleaded with first responders.

“Don’t let her die! Don’t let her die! Amanda, you come back to me!” they shouted in grief. 

The decisions paramedics and doctors made over the next few hours would save Boley’s life. They also triggered an agonizing battle between Boley and her insurance company — a battle that raises significant questions about how insurance companies are now doing business. 

Boley suffered cardiac arrest, the sudden loss of all heart activity due to an irregular heart rhythm.

A doctor at Norton King’s Daughters’ Hospital in nearby Madison, Ind., determined the medical help Boley needed was not available locally, and he quickly ordered paramedics to take her to a full-service hospital. The closest one was in Louisville.

The EMS crew determined the drive would take about an hour — time their patient did not have due to her grave medical condition. So the doctor told paramedics to take Boley to Madison Municipal Airport, where an air ambulance was waiting to transport her to Norton Brownsboro Hospital in Kentucky in less than 20 minutes.

That’s where surgeons operated on Boley and implanted a defibrillator in her chest to regulate her heartbeat. She woke up in the hospital two days later surrounded by IVs and monitors, and her family explained what had happened.

Boley credits her dog, her family and first responders for getting her immediate care that saved her life. But she said without the air ambulance, all of those efforts would have been in vain.

“If it weren’t for the helicopter, I’d be dead,” she told 13News.

So a few weeks later, as Boley was reviewing all the medical bills paid by her insurance company, imagine her surprise to find one of the medical expenses was denied: the bill for the helicopter transport.

“They were denying the claim because it didn’t get preapproved,” she explained.

Boley showed 13 Investigates an explanation of benefits (EOB) from Anthem Blue Cross and Blue Shield that said the insurance company would not pay for the air ambulance because “This service requires preapproval. Your plan doesn’t cover this service without it. You are responsible for this amount.”

The amount Boley was responsible for: $64,998.

“I cried. I felt sick because how am I going to pay that?” she said.  “And then I decided, ‘Well, I’m going to look at my policy.’ And my policy said preapproval may be required. So then my thought was, ‘Dry the tears. OK, this definitely has to be something that doesn’t need preapproval.”

Boley appealed, sending Anthem details and documents about her dire medical condition that showed she had suffered a life-threatening emergency that justified the helicopter and rendered her unable to get preapproval.

“I do not agree with this decision. I want an independent external review,” Boley wrote. “I am certain my diagnosis will be on the list where preapproval is not required. The transport via helicopter was medically necessary and transport any other way would have posed a threat to my survival or seriously endangered my health.”

But it didn’t work. Anthem turned down her appeal — not once, but twice.

“I appealed and they denied, and I appealed and they denied,” Boley explained, holding two separate letters from Anthem.

The insurance company doubled down on its preauthorization requirement, insisting “Your claim was processed correctly. Air ambulance services are subject to medical necessity reviews by us and will only be covered when approved in advance (before services are performed). There is no preauthorization on file approving this service.”

“That night I was dead and then I was unconscious. I don’t know how I’m supposed to get preapproval,” Boley said as she looked at her denial letters. “It’s outrageous.”

“She was in no way, shape or form able to call to get preauthorization. She was unresponsive,” the officer said incredulously after learning of the denials.

After battling her insurance company for months with no success, Boley said she felt depressed and scared at the thought of being saddled with a huge medical bill that her insurance company refused to cover.

“I don’t have $65,000 laying around. I don’t know many people who do. I just think it’s going to financially devastate me,” said Boley. 

In early January, Boley contacted 13 Investigates to explain her struggle with the insurance company. 13News then contacted Anthem on Boley’s behalf, requesting that the company further explain its denials and reverse its decisions.

An Anthem spokesman would not meet with 13News to discuss the case, but the company did send 13News a statement explaining that it made multiple errors while processing Boley’s claim. 

Jeff Blunt, Anthem’s senior director of corporate communications, told 13 Investigates:

“Emergency treatment never requires prior authorization, and our members can access emergency services 24/7 at any facility, regardless of network status. In this case, coverage decisions were made without the necessary information from the provider to recognize that this was an emergency. Once we became aware of the circumstances, we should have acted immediately to obtain that documentation and approve the claim—but we did not.

We deeply regret the mistakes that led to the incorrect determinations and our leadership has been in touch with our member to offer our sincere apologies. Anthem Blue Cross and Blue Shield is committed to ensuring our members receive timely and appropriate care. We take our responsibility to our members seriously and we are taking immediate steps to improve our processes to provide the high-quality service they deserve. These steps include a more personalized, proactive, and high-touch approach to addressing complex situations like this one.”

13News asked for additional information about the “immediate steps” Anthem is taking to improve its processes. A company spokeswoman responded by saying, “We are revisiting associate training procedures and documents to ensure it is clear how to handle these situations and prevent mistakes like this from happening in the future.”

13 Investigates also requested clarification about Anthem’s prior authorization policy. While the company insists “emergency treatment never requires prior authorization,” Anthem repeatedly sent Boley EOBs and appeal denial letters stating the opposite.

“Our policies are clear. We made a mistake in this situation,” wrote Janey Kiryluik, vice president of corporate communications for Elevance Health, which is the legal name for Anthem. “The original claim was processed incorrectly. As a result, when we received the appeals, we mistakenly treated them as needing prior authorization, tying them to the initial incorrect claim denial. This was an error on our part, and we sincerely regret the mistakes that led to the incorrect decisions and miscommunication with the member.”

The company also sent 13News a link to an online notice for medical providers underscoring its preauthorization policy during medical emergencies. “In the event of an emergency, members may access emergency services 24/7 at any Indiana Health Coverage Programs-enrolled provider/facility. The provider/facility does not have to be in-network,” the policy statement says. (Anthem has not yet provided 13 Investigates with any online notices that communicate that policy to its members.)

After 13News’ inquiry, Boley said she received a cordial phone call from a representative at Anthem who apologized for the erroneous denials. He also informed her that Anthem was going to fully cover the bill for her air ambulance transport.

“He indicated there were missteps, breakdowns and the claim should have been covered from the start, that I wasn’t listened to, and apologized. He indicated a check to cover the claim should be cut today and [Anthem] will work to ensure it doesn’t happen to anyone else,” Boley said, expressing relief. 

While Boley is no longer facing a huge medical bill for her air ambulance transport, how her case was handled still raises concerns.

“It doesn’t even make sense,” said Patricia Kelmar, senior health care campaign director at the U.S. Public Interest Research Group (PIRG), which tracks public health issues affecting consumers. Kelmar said she hears every day about patients like Boley who are forced to battle insurance companies over improper denials. “It seems like a disconnect, and the patient is left with this huge bill that cannot be right. That’s not how our system is supposed to be working with insurance … We’re hearing from patients all the time how difficult it is to use claim appeals and how powerless the patient really feels to be able to fight against a big insurance company.”

An estimated 450 million health insurance claims are now denied each year and the number is growing, according to healthcare company Premier, Inc. Some consumer watchdogs worry it’s because decisions are being made by computers — not people.

“We know right now that insurance companies are using AI [artificial intelligence] to deny claims,” Kelmar said. “These are individuals that have medical records, medical histories that may not fit into an AI model, and so it’s important that there’s a real human being that’s looking at this information and making those claim denial decisions for that individual patient.”

Was artificial intelligence used to evaluate and repeatedly deny Amanda’s claims — or was it a human being who made those mistakes?

Anthem has not responded to that question from 13 Investigates.

Either way, Patricia said when medical claims are denied, patients should fight.

“They should certainly appeal. What we’ve seen in studies is at least 50% — and there have been reports of as high as 75% — of the time, patients will win that appeal. So it’s absolutely worth filing the paperwork, going through the application process to get your insurance to cover your claim,” Kelmar told 13News. 

Boley said in her case, an appeal should never have been necessary.

“It’s appalling. It’s outrageous,” she said. “When people need help in a crisis situation like that, they have insurance for a reason. It’s to help when those situations happen.” 

If your healthcare claim is denied by an insurance company, Kelmar said there are several steps consumers can take to help get an improper denial reversed: 

Review your policy: First, know what your policy says, including what’s covered and what’s not. “Once you understand your policy, you’re a better position to know whether an appeal is appropriate,” Kelmar said.

File an appeal: Kelmar said few consumers appeal their insurance denials, but those who do often win. “If you believe you should have had coverage for something, you should certainly appeal,” she said. Make sure to include any details and documentation that will help support your claim.

Get your employer involved: If your insurance is provided through work, contact your human resources department to ask for support. “Chances are, your company is a very important client to that insurance company. Ask your HR department to get involved in this because sometimes the power of the employer, who’s paying for that insurance, is a bigger voice than you as an individual patient,” Kelmar explained. She said most HR departments are willing to advocate on their workers’ behalf. 

Appeal again: Persistence can pay off. If you are convinced your insurance company is still improperly denying your claim, appeal again and ask for your claim to be escalated to a manager. A different perspective might result in a different result.

File a complaint: If all else fails and your appeals are still denied, Kelmar recommends filing a complaint with regulators. If you have a state-regulated plan, file with your state department of insurance. If you have an employer-funded insurance plan, you will likely need to submit your complaint with the U.S. Department of Labor. “If you believe the company made a mistake, tell them about it and tell them how difficult the claim process and the appeal process was. The regulators need to hear about that,” she said.