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MP 10.01.05

Ambulance and Medical Transport Services


 

Medical Policy    
Section
Administrative
Original Policy Date
4/1/98
Last Review Status/Date
Reviewed by consensus/4:2003
Issue
4:2003
  Return to Medical Policy Index

Disclaimer

Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract.  Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage.  Medical technology is constantly changing, and we reserve the right to review and update our policies periodically.

 


 

Description

Ambulance and medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients. These services may involve ground, air, or sea transport in both emergency and nonemergency situations.

 


 

Policy

Ground emergency medical transport services are medically necessary when 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;
  • 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 an organ transplantation, to the approved transplant facility.

 

In exceptional circumstances, air or sea ambulance services may be medically necessary. In these circumstances, all of the criteria pertaining to ground transportation must be met as well as the following:

  • The patient’s medical condition requires immediate and rapid ambulance transport that could not have been provided by land ambulance;
  • 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 patient’s condition is such that the time needed to transport a patient by land poses a threat to the patient’s health.

Nonemergency medical transport services are medically necessary when 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 patient is a registered inpatient in an acute care hospital and the specialized services are not available in that hospital;
  • The provider of the specialized service is the nearest one with the required capabilities.

 


 

Policy Guidelines

The ambulance services are not considered medically necessary if the patient is legally pronounced dead before the ambulance was called. The services are considered eligible for coverage if the patient is legally pronounced dead after the ambulance was called, but before pickup, or en route to the hospital.

 


 

Benefit Application

BlueCard/National Account Issues

All devices are considered an integral part of the ambulance and medical transport services and no additional benefits are provided for reusable or disposable devices or supplies.

Benefits are not provided for medical transport to nursing facilities, physician’s offices, or patient’s home.

 

Some Plans offer riders for air or sea ambulance services. If a member or group does not accept this rider, the Plan may consider reimbursement in these situations up to the limits of the ground ambulance benefits.

 

If a life-support ambulance is used, the equipment must also be used for it to be covered.

 


 

Rationale

The data compiled for this policy were a combination of local Plan policies and claims experience (only two sources were cited because standard billing practices were not ascertainable).

 

Codes

Number

Description

CPT  No Code   
ICD-9 Procedure  No Code   
ICD-9 Diagnosis  No Code   
HCPCS  A0429  Ambulance service, basic life support, emergency transport 
  A0427  Ambulance service, advanced life support, emergency transport, level 1 
  A0433  Advanced life support, level 2 
  A0430-A0431;
 
A0435-A0436 
Ambulance service, conventional air services, transport, one way – code series 
  A0080 – A0210  Non-emergency transportation (code range) 
  A0225   Ambulance service, neonatal transport, base rate, emergency transport, one way 
  A0380  BLS mileage (per mile) 
  A0382–A0384  BLS disposable supplies (code range) 
  A0390  ALS mileage (per mile) 
  A0392–A0398  ALS disposable supplies (code range) 
  A0420  Ambulance waiting time 
  A0422  Ambulance oxygen and oxygen supplies, life-sustaining situation 
  A0424  Extra ambulance attendant 
  A0425  Ground mileage, per statute mile 
  A0888  Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) 
  A0999  Unlisted ambulance service 
Type of Service  Medical 
Place of Service  Inpatient
 
Home
 
Physician’s Office
 

 


 

Index

Air ambulance
Ambulance services
Medical transport services
Transport, medical and ambulance

 


 

Policy History

Date Action Reason
05/03/97 Add to Administrative section New policy
04/01/98 Replace policy Policy reviewed, formatting changes only
05/15/02 Replace policy Policy reviewed without literature review; new review date only
12/17/03 Replace policy Policy reviewed by consensus without literature review; no changes in policy other than updating HCPCS codes; no further review scheduled.