Archived Policies - Administrative


Ambulance and Medical Transport Services

Number:ADM1001.005

Effective Date:09-15-2004

End Date:11-14-2007

Coverage:

Ambulance services are medically necessary as outlined below:

  • the medical transport services must comply with all local, state, and federal laws, and must have all the appropriate valid licenses;
  • the ambulance or other medical transport services must have the necessary patient care equipment and supplies;
  • the patient's condition must be such that any other form of transportation would be medically contraindicated;
  • the patient is transported to the nearest site with the appropriate facilities for the treatment of the injury or illness involved or in the case of organ transplantation, to the approved transplant facility; and
  • coverage will be extended to the next nearest facility generally equipped to provide the needed care, IF
    1. no bed is available at the nearest facility,
    2. the trauma unit is full, or
    3. a specialist or surgeon is not on call or is not available at the nearest facility.

Air or sea ambulance services are medically necessary as outlined below:

  • the time needed to transport a patient by either basic or advanced life support land ambulance poses a threat to survival;
  • the point of pick-up is inaccessible by land vehicle;
  • great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment (e.g., transport of a critically ill patient to an approved transplant facility with a waiting organ).

The following services are NOT medically necessary, as they do not require ambulance transportation:

  • ambulance services when the patient has been legally pronounced dead prior to the ambulance being summoned;
  • services provided by an ambulance crew who do not transport a patient but only render aid. Some examples are:
    1. ambulance dispatched to scene of an accident and crew renders aid until a helicopter can be sent;
    2. ambulance dispatched and patient refuses care; or
    3. ambulance dispatched and only basic first aid is rendered.

Non-emergency transports are defined as ambulance transports for a patient who has a medical problem requiring treatment in another location and is so disabled that the use of an ambulance is the only appropriate means of transfer. Disabled means the patient's physical condition limits his/her mobility and is unable to stand and sit unassisted or requires continuous life support systems.

Examples of situations where non-emergency transportation is medically necessary for the patient described above include the following services:

  • transfer from a hospital to a renal dialysis facility furnishes services to the patients of a hospital on an outpatient basis,
  • Round trip transportation from a skilled nursing facility to freestanding facilities (such as Renal dialysis facility or Radiation therapy center), OR
  • Hospice patient transferred from hospital to home or from home to hospital.

Transfers by medical vans or commercial transportation (such as physician owned limousines, public transportation, cabs, etc.) are NOT medical transport and are not considered medically necessary.

Description:

Ambulance services involve the use of a specially designed and equipped automotive or other vehicle, licensed by the state, and regulated by local, state and federal laws, to transport the ill or injured. Ambulances can be classified as either basic life support or advanced life support depending upon how the vehicle is equipped. This in turn regulates the level of care that can be provided in the actual transport.

Basic Life Support (BLS) vehicles must be staffed by at least two people, one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished. The EMT must be legally authorized to operate all lifesaving and life sustaining equipment on the vehicle.

Advanced Life Support (ALS) vehicles must be staffed by two people with one of the two staff members certified as a paramedic or an EMT who is trained and certified (by the State or local authority where the services are being furnished) to perform one or more ALS service.

Rationale:

Coverage for ambulance service is a contract issue as well as a medical necessity issue. Ambulances are sometimes misused for non-emergency situations.

This policy describes situations where it would be medically necessary and appropriate to use ALS, BLS, or non-emergency levels of ambulance services.

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

Refer to any State specific Corporate Guidelines in effect for payment information.


Medicare Coverage:

None

References:

National Institutes of Health, NIH News Release, Education Study Increases Ambulance Use But Yields No Extra Improvement in Heart Attack Patient Delay Time. July 4, 2000.

1997 Medicare Part B Specialty Workshops, Ambulance.

BSBSA Medical Policy Reference Manual. Ambulance and Medical Transport Services. 10.01.05, (5/30/97).

Policy History:

Archived Document(s):

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