POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY

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1 Original Issue Date (Created): 7/1/2002 Most Recent Review Date (Revised): 1/27/2015 Effective Date: 6/1/2015 POLICY PRODUCT VARIATIONS DESCRIPTION/BACKGROUND RATIONALE DEFINITIONS BENEFIT VARIATIONS DISCLAIMER CODING INFORMATION REFERENCES POLICY HISTORY I. POLICY When a benefit, this policy addresses general guidelines that apply to ambulance services and should be used in conjunction with the member s benefits, the network provider s plan agreement, and any applicable ambulance billing guidelines. Non-Emergency Ambulance Transportation (Land) (ALS or BLS) Non-emergent ambulance transport (land) may be considered medically necessary when there is documented clinical evidence of the following: The patient is bed confined and the patient s condition is such that other methods of transport are contraindicated; OR, The patient s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required (see guidelines) Guidelines The following criteria may be useful in determining the medical requirement for nonemergency ambulance transport: Is the patient s medical condition, at the time of transportation, such that the patient must be transported on a stretcher in an ambulance and transport by any other means is contraindicated? Could the patient be safely transported in a wheelchair van, stretcher van, car or taxi, without a medical attendant? Does the patient require cardiac/hemodynamic monitoring or medication administration (including oxygen), which requires monitoring or adjustment while in transit? Does the patient require skilled services of a paramedic or BLS ambulance personnel? Page 1

2 Does the patient have a benefit for non-emergency ambulance transport? Does the patient have a benefit for non-emergency, non-ambulance transport (i.e. wheelchair van, stretcher van, or other type of invalid coach)? Air Ambulance Use of an air ambulance may be considered medically necessary to transport a patient to the closest medical facility with the capability of treating the patient s condition when: The patient s condition is such that the time needed to transport a patient by ground, or the instability of transportation by ground, poses a threat to the patient s survival or seriously endangers the patient s health and either: o The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), OR o Great distances or other obstacles (e.g. traffic) are involved in getting the patient to the nearest hospital with appropriate facilities for treatment. Examples of cases for which air ambulance could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed. Intracranial bleeding requiring prompt neurosurgical intervention; Cardiogenic shock; Burns requiring treatment in a burn center; Conditions requiring treatment in a Hyperbaric Oxygen Unit; Multiple severe injuries; or Life-threatening trauma. Air ambulance transport may also be considered medically necessary for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the patient s health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Page 2

3 Transport from a hospital capable of treating the patient because the patient and/or the patient s family prefer a specific hospital or physician is considered not medically necessary. Air ambulance services for transport to a facility that is not an acute care hospital, such as a nursing facility, physician s office or a member s home are considered not medically necessary. Air ambulance transportation service is performed by either a rotary wing aircraft (RW) (e.g., helicopter) or fixed wing aircraft (FW) (e.g. airplane), specially designed and equipped for transporting the sick or injured. It must have customary patient care equipment and supplies and also must have safety and lifesaving equipment. The ambulance crew must consist of at least two attendants. One of these attendants must be qualified to provide the medical care required during transport. Inter-facility Transportation Medical transportation services between hospitals and freestanding diagnostic/treatment facilities or other acute hospitals may be considered medically necessary when all of the following conditions are met: The BLS/ALS or air transport meets prior documented medical necessity criteria; Medically necessary services required to treat a patient s condition are not available in the original facility; The Member is transported to the most appropriate hospital or freestanding diagnostic/treatment facility that can provide the necessary service; o The Member becomes an inpatient either in the original or receiving facility; o The transportation service is not rendered for the convenience of the patient, the patient s family or provider; and o Alternate transportation is not feasible or reasonable Cross-reference MP Medical Necessity II. PRODUCT VARIATIONS [N] = No product variation, policy applies as stated [Y] = Standard product coverage varies from application of this policy, see below Page 3

4 [N] Capital Cares 4 Kids [N] PPO [N] HMO [Y] SeniorBlue HMO* [Y] SeniorBlue PPO* [N] Indemnity [N] SpecialCare [N] POS [N] FEP PPO *Refer to Novitas Solutions Local Coverage Determination (LCD) L Ambulance (Ground) Services. Also refer to CMS On-Line Manual Pub , Chapter 10, and Chapter 15 III. DESCRIPTION/BACKGROUND 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 or air transports in both emergency and non-emergency situations. Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, as well as non-emergency situations. The vehicle must comply with state and local laws governing the licensing and certification of an emergency medical transport vehicle. At a minimum, the vehicle must contain a stretcher, linens, emergency medical supplies, and oxygen equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state and local law According to Section 8129(a) of the Emergency Medical Services System Act (EMS System Act) of Pennsylvania, if a person requires stretcher van or wheelchair van attendants to administer, assess, monitor, treat or observe a person- including the delivery of oxygen to a person, while that person is being transported- or the oxygen is being provided by the transport agency the operators of the transport vehicle are in violation of the EMS System Act for providing EMS without holding a license as an EMS agency and not using a licensed ambulance. IV. RATIONALE NA V. DEFINITIONS ADVANCED LIFE SUPPORT (ALS) is the delivery of pre-hospital or inter-hospital emergency medical care for serious illness or injury. ALS includes the administration of intravenous therapy, cardiac (EKG) monitoring, and defibrillation of the heart. Page 4

5 BASIC LIFE SUPPORT AMBULANCE (BLS) is the delivery of pre-hospital or inter-hospital emergency medical care and the management of illness and injury, such as administration of oxygen and first aid (e.g., splinting of fractures, pressure bandages, and cardio-pulmonary resuscitation). MEDICAL EMERGENCY - A medical condition with acute symptoms of such severity that: Care is sought as soon as possible after the medical condition becomes evident to the patient or the patient s parent or guardian; and The emergency involves the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity or severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: o Undo risk to the health of the Member, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy: Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part. BED CONFINED means that ALL three conditions below are met: Unable to get up from bed without assistance Unable to ambulate; and Unable to sit in a chair or wheelchair INVALID COACH Invalid coach means a motor vehicle designed, equipped, and used for the transportation of invalid persons on a non-emergency basis. Such vehicles shall require no personnel other than the driver and shall not be required to have first-aid equipment, flashing red lights or sirens. Wheelchair vans and stretcher vans are examples of invalid coach services. VI. BENEFIT VARIATIONS The existence of this medical policy does not mean that this service is a covered benefit under the member's contract. Benefit determinations should be based in all cases on the applicable contract language. Medical policies do not constitute a description of benefits. A member s individual or group customer benefits govern which services are covered, which are excluded, and which are subject to benefit limits and which require preauthorization. Members and providers should consult the member s benefit information or contact Capital for benefit information. Page 5

6 VII. DISCLAIMER Capital s medical policies are developed to assist in administering a member s benefits, do not constitute medical advice and are subject to change. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any medical policy related to their coverage or condition with their provider and consult their benefit information to determine if the service is covered. If there is a discrepancy between this medical policy and a member s benefit information, the benefit information will govern. Capital considers the information contained in this medical policy to be proprietary and it may only be disseminated as permitted by law. VIII. CODING INFORMATION Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement. Covered when medically necessary: CPT Codes Current Procedural Terminology (CPT) copyrighted by American Medical Association. All Rights Reserved. HCPCS Code A0130 A0225 A0380 A0382 A0384 A0390 A0392 A0394 A0396 A0398 A0420 A0422 Description Nonemergency transportation: wheelchair van Ambulance service, neonatal transport, base rate, emergency transport, one way BLS mileage (per mile) BLS routine disposable supplies BLS specialized service disposable supplies; defibrillation (used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances) ALS mileage (per mile) ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed in BLS ambulances) ALS specialized service disposable supplies; IV drug therapy ALS specialized service disposable supplies; esophageal intubation ALS routine disposable supplies Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation Page 6

7 HCPCS Code Description Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires A0424 medical review) A0425 Ground mileage, per statute mile A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - A0427 emergency) A0428 Ambulance service, basic life support, nonemergency transport, (BLS) A0429 Ambulance service, basic life support, emergency transport (BLS, emergency) A0430 Ambulance service, conventional air services, transport, one way (fixed wing) A0431 Ambulance service, conventional air services, transport, one way (rotary wing) Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company A0432 which is prohibited by state law from billing third-party payers A0433 Advanced life support, level 2 (ALS 2) A0434 Specialty care transport (SCT) A0435 Fixed wing air mileage, per statute mile A0436 Rotary wing air mileage, per statute mile A0888 A0998 A0999 Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) Ambulance response and treatment, no transport Unlisted ambulance service Specific diagnoses do not apply to this medical policy* *If applicable, please see Medicare LCD or NCD for additional covered diagnoses. IX. REFERENCES Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter 10, Ambulance Services, and Chapter 15, Covered Medical and Other Health Services. Revised [Website]: Guidance/Guidance/Manuals/downloads//bp102c10.pdf Accessed December 23, Novitas Solutions. Local Coverage Determination (LCD) L Ambulance (Ground) Services Effective09/1/14. Accessed December 31, Page 7

8 Air Ambulance Bulger E, Guffey D, Guyette F, et al. Impact of prehospital mode of transport after severe injury: A multicenter evaluation from the resuscitation outcomes consortium. JTrauma Acutecare Surg March;72(3): Accessed December 23, Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication Chapter 10, Ambulance Services, and Chapter 15, Covered Medical and Other Health Services. Revised [Website]: Accessed December23, Galvagno SM Jr, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA Apr 18;307(15): X. POLICY HISTORY MP CAC 10/26/04 CAC 5/25/04 CAC 9/13/05 CAC 6/27/06 CAC 6/26/07 CAC 5/27/08 CAC 5/26/09 CAC 5/25/10 Consensus Review CAC 4/26/11 Consensus Review, deleted information regarding enhanced non ambulance transport for Sr. Blue HMO and Sr. Blue PPO. Communication was provided Admin Change 4/12/12 Medicare variation revised. CAC 3/26/13 Administrative review. Reviewed COCs and updated statements to assure language is consistent with benefits for all products listed. 03/04/2013- Coding reviewed-skb CAC 01/28/14 Consensus Review. No change to statements. Codes reviewed. Air ambulance transportation is covered only when the transport is medically necessary or the point of pick-up is not accessible by land, and the transport is to an acute care hospital (whether for initial transport or subsequent transfer to another facility for special care). Page 8

9 5/23/14 Administrative change: Changed non-emergency air facility to facility transport for all products from noncovered to reflect current COC language which indicates Air ambulance transportation is covered only when the transport is medically necessary or the point of pick-up is not accessible by land, and the transport is to an acute care hospital (whether for initial transport or subsequent transfer to another facility for special care). CAC 1/27/15 Minor revision. Product specific tables have been removed from the policy. All users should refer to benefit documents regarding land, air ambulance and non-emergency transport. Policy now addresses in further detail when air ambulance services are medically appropriate. FEP variation removed. Coding reviewed. Top Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company, Capital Advantage Assurance Company and Keystone Health Plan Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Page 9

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