Archived Policies - Administrative


Ambulance and Medical Transport Services

Number:ADM1001.005

Effective Date:07-15-2015

End Date:07-31-2016

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; or

Serious impairment to the individual’s bodily functions; or

Serious dysfunction of the individual’s bodily organs or parts.

I. Emergency Ground Ambulance Transport

A. 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; and

The ambulance or other medical transport services must have the necessary patient care equipment and supplies; and

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

A. 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 in Section I are met, and 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

A. Emergency air ambulance transport services from a Health Care Facility/Hospital Emergency Department or Inpatient Setting may be considered medically necessary when ALL of the following criteria are met:

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

A. 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 ALL of the following criteria are met:

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.

B. 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.

C. 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.

A. 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; and

The patient requires services that are unavailable at the originating facility; and

The receiving hospital is the nearest one with the required capabilities; and

The patient cannot be safely discharged from inpatient setting; and

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).

B. 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:

Basic first aid is when an individual provides emergency aid or treatment to someone that is injured or suddenly ill prior to the arrival of medical services. Once the individual is assessed by a trained medical professional, it may be determined that transport services may be indicated to move the individual to a higher level of care.

Ambulance transport services involve the use of specially designed and equipped vehicles, 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. The means of transport must be staffed by individuals who are qualified in accordance with State and local laws. These laws may vary from State to State or within a State.

Levels of transport include:

  • Basic Life Support;
  • Advanced Life Support, Level 1;
  • Advanced Life Support, level 2;
  • Specialty Care Transport.

Definitions:

Advanced Cardiac Life Support (ACLS)

A constellation of clinical interventions for the urgent treatment of cardiac arrest, stroke and other life-threatening medical (non-traumatic) emergencies in which basic life support efforts of cardiopulmonary resuscitation (CPR) are augmented. ACLS may include airway management, vein assessment, interpretation of Electrocardiogram (ECG/EKG), application of emergency pharmacology and early defibrillation with automated external defibrillators (AED) as needed.

Advanced Life Support, level 1 (ALS1)

When medically necessary, includes the transportation by a ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment or at least one ALS intervention.

Advanced Life Support, level 2 (ALS2) Includes the transportation by a ground ambulance vehicle and the provision of medically necessary supplies and services including at least 3 separate administrations of 1 or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids) OR at least 1 of the ALS2 procedures listed below (1):

a) Defibrillation/cardioversion;

b) Endotracheal intubation;

c) Central venous line;

d) Cardiac pacing;

e) Chest decompression;

f) Surgical airway; or

g) Intraosseous line.

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. 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. Some states permit licensed EMT personal to perform skills and roles beyond the minimum skill set as they gain knowledge, additional education and experience. (1) Each state has an individualized defined scope of practice; generally the duties of the EMT-Basic may include at a minimum, but are not limited to, the following interventions (1,2):

o Administration of over the counter medications with appropriate medical oversight;

o Assessment and management of airway (e.g., oropharynx or nasopharynx);

o Stabilization of fractures;

o Use of positive pressure ventilation (PPV) devices (e.g., manually triggered ventilators, automatic transport ventilators).

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 (1,2).

Emergency-

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.

Specialty Care Transport (SCT)-

When medically necessary, it includes the provision of medically necessary supplies and services beyond the scope of an Emergency Medical Technician-Paramedic (EMT-Paramedic). SCT is the inter-facility transportation of a critically ill or injured individual is necessary because the individual’s condition requires ongoing medical care furnished by one or more professionals in an appropriate specialty (such as emergency or critical care nursing, emergency medicine, respiratory or cardiovascular care). (1)

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:

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. Centers for Medicare &
Medicaid Services. Medicare Ambulance Transports (June 2014). <http://www.cms.gov>. Last accessed May 7 2015. ICN903194.

2. The National Highway Traffic Safety Administration. National EMS Scope of Practice Model. (February 2007). Available online at <www.ems.gov/education>. Last accessed May 14, 2015.

3. Yee, Linton L. What is the Difference between CPR, BLS, and PALS (2013)? Available online at: <www.dukechildrens.org>. Last accessed May 5, 2015.

4. Medicare Benefit Policy Manual, Chapter 10 (revised 2014) – Ambulance Services. Available online at: <http://www.cms.gov>. Last accessed April 2015.

5. Ambulance and Medical Transport Services- Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Administrative 10.01.05.

Policy History:

Date Reason
7/15/2015 Document updated with literature review. The following editorial change was made to Coverage: 1) added “ ALL of the following criteria are met” to section 1A, Non-Emergency Ground Ambulance Transport.
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
11/1/1997 Revised/updated entire document
5/1/1996 Revised/updated entire document
1/1/1992 Revised/updated entire document
9/1/1991 Revised/updated entire document

Archived Document(s):

Back to Top