Archived Policies - Administrative
Ambulance and Medical Transport Services
This medical document is no longer scheduled for routine literature review and update.
Ground ambulance transport services may be considered medically necessary as outlined below:
Air or sea ambulance transport services may be considered medically necessary as outlined below:
Ambulance services without transportation may be considered medically necessary when the patient requires basic life support or advanced life support services.
The following services are considered NOT medically necessary:
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 the patient is unable to stand and sit unassisted or requires continuous life support systems.
Examples of situations where non-emergency transportation may be considered medically necessary for the patient described above include (but are not limited to) the following services:
Transfers by medical vans or commercial transportation (such as physician owned limousines, public transportation, cabs, etc.) are NOT medical transport and are considered not medically necessary.
Ambulance services involve the use of a specially designed and equipped 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.
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
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.
Refer to State specific Guidelines in effect for payment information.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0215, A0225, A0382, A0384, A0392, A0394, A0396, A0398, A0420, A0422, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998, A0999, S0207, S0208, S0209, S0215, S9960, S9961
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
ICD-10 Procedure Codes
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
Medicare does not have a national coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed or changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1997 Medicare Part B Specialty Workshops, Ambulance.
Ambulance and Medical Transport Services. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Manual. (1997 May 30l) Administrative 10.01.05.
National Institutes of Health, NIH News Release, Education Study Increases Ambulance Use But Yields No Extra Improvement in Heart Attack Patient Delay Time (2000 July 4).
Ambulance and Medical Transport Services. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Manual. (2003 April) Administrative 10.01.05.
|Title:||Effective Date:||End Date:|
|Ambulance and Medical Transport Services||06-15-2019||05-31-2020|
|Ambulance and Medical Transport Services||12-15-2018||06-14-2019|
|Ambulance and Medical Transport Services||07-01-2018||12-14-2018|
|Ambulance and Medical Transport Services||10-01-2017||06-30-2018|
|Ambulance and Medical Transport Services||12-01-2016||09-30-2017|
|Ambulance and Medical Transport Services||08-01-2016||11-30-2016|
|Ambulance and Medical Transport Services||07-15-2015||07-31-2016|
|Ambulance and Medical Transport Services||09-15-2014||07-14-2015|
|Ambulance and Medical Transport Services||08-01-2008||09-14-2014|
|Ambulance and Medical Transport Services||11-15-2007||07-31-2008|
|Ambulance and Medical Transport Services||09-15-2004||11-14-2007|
|Ambulance and Medical Transport Services||07-01-2004||09-14-2004|
|Ambulance and Medical Transport Services||11-01-1997||06-30-2004|