Archived Policies - Administrative


Ambulance and Medical Transport Services

Number:ADM1001.005

Effective Date:09-15-2014

End Date:07-14-2015

Coverage:

CAREFULLY REVIEW the member’s benefit plan, summary plan description or contract for ambulance coverage provisions. 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.

***EMERGENCY AMBULANCE TRANSPORT SERVICES***

An emergency is the sudden onset, or significant worsening of a medical condition that manifests itself by symptoms of sufficient severity or pain, and that in the absence of immediate medical transport could reasonably be expected by the prudent layperson to result in:

  • The health of the individual being placed in serious jeopardy;
  • Serious impairment to the individual’s bodily functions; or
  • Serious dysfunction of the individual’s bodily organs or parts.

I.      Emergency Ground Ambulance Transport

Emergency ground ambulance transport services may be considered medically necessary when ALL of the following criteria are met:

  • The medical transport services must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits;
  • 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; and
  • The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of organ transplantation, to the approved transplant facility.

II.      Emergency Air Ambulance Transport from Site of Accident, Injury or Illness

Emergency air ambulance transport services from the site of accident, injury or illness may be considered medically necessary when the criteria for emergency ground ambulance transport are met, as well as one of the following:

  • The point of pick-up is inaccessible by land vehicle; OR
  • The total estimated time from initial call for transportation to arrival of the patient at the receiving facility is projected to be significantly (at least one hour) shorter for air ambulance than for ground ambulance (Note: This takes into account the relative proximity of the ambulance to the scene, availability of crews, time to mobilize the aircraft, and the total distance traveled.) AND the patient is in critical condition and/or has unstable vital signs, respiratory status or cardiac status, including but not limited to one of the following conditions:

           o  Intracranial bleeding requiring emergent intervention;

           o  Cardiogenic shock;

           o  Acute myocardial infarction requiring emergent intervention;

           o  Burns requiring immediate treatment in a Burn Center;

           o  Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;

           o  Multiple severe injuries;

           o  Life-threatening trauma;

           o  Transplants;

           o  High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus).

III.      Emergency Air Ambulance Transport from a Health Care Facility/Hospital Emergency Department or Inpatient Setting

Emergency air ambulance transport services from a Health Care Facility/Hospital Emergency Department or Inpatient Setting may be considered medically necessary when the criteria for emergency ground ambulance transport are met, as well as ALL of the following:

  • The patient requires acute medical or surgical intervention(s) that the transferring facility cannot provide; AND
  • The patient is being transferred to an equivalent or higher level of acuity inpatient facility; AND
  • The total estimated time from initial call for transportation to arrival of the patient at the receiving facility is projected to be significantly (at least one hour) shorter for air ambulance than for ground ambulance (Note: This takes into account the relative proximity of the ambulance to the scene, availability of crews, time to mobilize the aircraft, and the total distance traveled.); AND
  • The patient is in critical condition, has unstable vital signs, unstable respiratory or cardiac status and/or one of the following conditions:

            o  Intracranial bleeding requiring emergent intervention;

            o  Cardiogenic shock;

            o  Acute myocardial infarction requiring emergent intervention;

            o  Burns requiring immediate treatment in a Burn Center;

            o  Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;

            o  Multiple severe injuries;

            o  Life-threatening trauma;

            o  Transplants;

            o  High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus).

***NON-EMERGENCY AMBULANCE TRANSPORT SERVICES***

Non-emergency conditions are conditions that require medical attention, which may be provided or directed by a physician, but are not severe enough to meet this policy’s definition of emergency.

 I.      Non-Emergency Ground Ambulance Transport

Non-emergency ground ambulance transportation from one acute care hospital to another acute care hospital for diagnostic or therapeutic services (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services, etc.) may be considered medically necessary when:

  • The patient is a registered inpatient; and
  • The services are medically necessary for the immediate care of the patient; and
  • The services are unavailable at the originating facility; and
  • The receiving hospital is the nearest one with the required capabilities.

Non-emergency ground ambulance transportation to or from a hospital or medical facility, outside of the acute care hospital setting, may be considered medically necessary when:

  • The patient’s condition is such that trained ambulance attendants are required to monitor the patient’s clinical status (e.g., vital signs and oxygenation), or treatments such as oxygen, intravenous fluids, or medications, in order to safely transport the patient; OR
  • The patient is confined to bed and cannot be safely transported by any other means.

Non-emergency ground ambulance transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility are considered not medically necessary.

II.      Non-Emergency Air Ambulance Transport

Note:  Any situations not meeting the criteria for emergency air ambulance transport from a Health Care Facility/Hospital Emergency Department or Inpatient Setting are considered non-emergency situations.

Non-emergency air ambulance transportation from a Health Care Facility/Hospital Emergency Department or Inpatient Setting to an equivalent or higher level of acuity facility may be considered medically necessary when all of the following criteria are met:

  • The patient requires acute inpatient care;
  • The patient requires services that are unavailable at the originating facility;
  • The receiving hospital is the nearest one with the required capabilities;
  • The patient cannot be safely discharged from inpatient setting;
  • The patient cannot be safely transported using commercial air transport; and
  • Ground ambulance transport is precluded due to adverse weather and/or road conditions (e.g., flooding, ice, or snow).

Non-emergency air ambulance transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility, including situations where long distances exist between the transferring and receiving facilities, are considered not medically necessary.

***OTHER***

Ambulance services without transportation may be considered medically necessary when the patient requires basic life support or advanced life support services.

The following ground or air transport services are considered not medically necessary:

  • Services for which the criteria listed above have not been met;
  • Services are for a patient that has been legally pronounced dead prior to the ambulance being called;
  • Services provided by an ambulance crew who do not transport a patient but only render basic first aid (e.g. ambulance dispatched and patient refuses care, ambulance dispatched and only basic first aid is rendered);
  • Non-medical transport services such as those provided by medical vans or commercial transportation.      

Description:

Ambulance transport 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 ill or injured patients. These services may involve ground or air transport in both emergency and non-emergency situations.

Ambulance transportation categories:

Basic Life Support (BLS): when medically necessary, the provision of BLS services as defined in the National EMS Education and Practice Blueprint for the EMT – Basic, including the establishment of a peripheral intravenous (IV) line. BLS provides techniques and skills included in an emergency medical technician (EMT) basic training course to individuals as they are transported to the nearest hospital.

Basic Life Support (BLS) – emergency: when medically necessary, the provision of BLS services, as specified above, in the context of an emergency response (defined below).

Advanced Life Support, level 1 (ALS1): when medically necessary, the provision of an assessment by an Advanced Life Support (ALS) provider or supplier or the provision of one or more ALS interventions. An ALS provider/supplier is defined as a provider trained to the level of the EMT-Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint. An ALS intervention is defined as a procedure beyond the scope of an AMT-Basic as defined in the National EMS Education and Practice Blueprint.

Advanced Life Support, level 1 (ALS1) – emergency: when medically necessary, the provision of ALS1 services, as specified above, in the context of an emergency response. An emergency response is one that, at the time the ambulance supplier is called, is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the beneficiary’s health in serious jeopardy; in impairment to bodily functions; or in serious dysfunction to any bodily organ or part.

Advanced Life Support, level 2 (ALS2): when medically necessary, the administration of three or more different medications and the provision of at least one of the following ALS procedures:

•           Manual defibrillation/cardioversion

•           Endotracheal intubation

•           Central venous line

•           Cardiac pacing

•           Chest decompression

•           Surgical airway

•           Intraosseous line.

Specialty Care Transport (SCT): when medically necessary, for a critically injured or ill beneficiary, a level of inter-facility service provided beyond the scope of the paramedic defined in the National EMS Education and Practice Blueprint. This is necessary when a beneficiary’s condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area, e.g., nursing, medicine, respiratory care, cardiovascular care, or a paramedic with additional training.

Advanced Life Support (ALS): ALS provides sophisticated medical care, such as cardiac monitoring, defibrillation, management of pediatric and obstetrical emergencies, and stabilization of individuals in critical or life threatening conditions as they are transported to the nearest hospital. The ALS ambulatory emergency medical technicians receive medical directions via radio contact with a hospital-based physician.

Rationale:

This is an administrative medical policy that describes situations in which ground and air ambulance transports may be considered appropriate.

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:

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.

CPT/HCPCS/ICD-9/ICD-10 Codes

The following codes may be applicable to this Medical policy and may not be all inclusive.

CPT Codes

N/A

HCPCS Codes

A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, 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

Refer to the ICD-10-CM manual

ICD-10 Procedure Codes

Refer to the ICD-10-CM manual


Medicare Coverage:

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.

The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.

A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

References:

1.     Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services. Available online at: <http://www.cms.gov>.  Last accessed February 2014.

Policy History:

Date                 Reason

9/15/2014        Document updated with literature review. The following changes were made to coverage: 1) Definitions of an emergency and non-emergency condition were added. 2) Ambulance transport by sea was removed. 3) Criteria for emergency air ambulance transport, non-emergency ground ambulance transport, and non-emergency air ambulance transport were completely revised. CPT/HCPCS code(s) updated.

8/1/2008          Legislation revised, added New Mexico legislation to policy.

11/15/2007      Revised/updated entire document

7/1/2004          Revised/updated entire document

11/1997           Revised/updated entire document

5/1996             Revised/updated entire document

1/1992             Revised/updated entire document

9/1991             Revised/updated entire document

Archived Document(s):

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