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 specialty care transport 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, including, but not limited to, when point of pickup is inaccessible by land vehicle, 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.
• 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 and/or life.

Specialty care 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 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. 

Effective Jan. 1, 2020, nonemergency transport will be considered MEDICALLY NECESSARY to transfer from a precertified inpatient hospital or skilled nursing facility to a precertified lower level of care admission when the member's condition makes other forms of transportation unfeasible (e.g., mechanical ventilation, traction). This transportation will require prior authorization according to the individual contract. 

Policy Guidelines:
Ambulance services are considered NOT MEDICALLY NECESSARY if the patient is not transported to a health care facility.

The ambulance services are considered NOT 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.

Coding Section

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. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2014 Forward