1 MEDICAL POLICY POLICY RELATED POLICIES POLICY GUIDELINES DESCRIPTION SCOPE BENEFIT APPLICATION RATIONALE REFERENCES CODING APPENDIX HISTORY Ambulance and Medical Transprt Services Number * Effective Date April 24, 2015 Revisin Date(s) 04/14/15; 06/09/14; 07/08/13; 09/11/12; 07/10/12 Replaces N/A *Medicare has a plicy. Plicy Ambulance and medical transprt services may be cnsidered medically necessary when the fllwing specific Emergency Medical Transprt Grund Emergency Medical Transprt Grund emergency medical transprt (ambulance) services may be cnsidered medically necessary when ALL f the fllwing Any ther frm f transprtatin wuld be medically cntraindicated due t the patient s cnditin. The patient must be transprted t the nearest hspital with the apprpriate level f services fr the treatment f the patient s illness r injury, r in the case f rgan transplantatin, t the apprved transplant facility. The emergency medical transprt services must cmply with all lcal, state, and federal laws and must have all the apprpriate, valid licenses and permits. The ambulance r ther grund emergency medical transprt vehicle must have the necessary persnnel, patient care equipment and supplies. Air/Sea Emergency Medical Transprt Air r sea emergency medical transprt services may be cnsidered medically necessary, in exceptinal circumstances, when ALL f the criteria fr grund emergency medical transprt and ALL f the fllwing Great distances, limited time frames, r ther bstacles prevent getting the patient t the nearest hspital with apprpriate facilities fr treatment, e.g., transprt f a critically ill patient t an apprved transplant facility with a waiting rgan. Due t the severity f the patient s cnditin* grund emergency medical transprt pses a threat t the patient s health and/r life. *Serius Health Cnditins Health cnditins that are severe enugh that air ambulance transprt culd be justified as medically necessary, may include, but are nt limited t:
2 Nte: Cnditins requiring treatment in a hyperbaric xygen unit Intracranial bleeding requiring neursurgical interventin Life-threatening shck, sepsis, r rgan failure requiring immediate interventin at an apprpriately equipped facility Life-threatening trauma requiring immediate surgical interventin at an apprpriately equipped facility Nenatal emergencies Severe burns Significant multi-system injuries The list abve is nt inclusive f all situatins that justify air transprtatin, nr is it intended t justify air transprtatin in all lcales under the circumstances listed. Hspital t Hspital Medical Transprt Grund ambulance transprt may be cnsidered medically necessary fr transfer f a patient frm ne hspital t anther hspital under the fllwing cnditins: The transferring hspital is nt equipped t prvide the apprpriate medical services needed by the patient; AND The receiving hspital is the nearest acute care facility equipped t prvide the apprpriate medical services** needed by the patient. **Examples f specialized medical services that may nt be available at all hspitals r acute care facilities include but are nt limited t: Burn care Cardiac care Critical care Trauma care Air-ambulance transprt may be cnsidered medically necessary t transfer a patient frm ne hspital t anther hspital when ALL f the criteria fr hspital-t-hspital grund transprtatin are met; AND Due t the severity f the patient s cnditin* grund emergency medical transprt pses a threat t the patient Transprt frm a hspital capable f treating the patient because the patient and/r the patient s family prefer a specific hspital r physician is cnsidered nt medically necessary. Nn-Emergency Medical Transprt Nn-emergency medical transprt services may be cnsidered medically necessary when ALL f the fllwing The medical transprt services must cmply with all lcal, state, and federal laws and must have all the apprpriate, valid licenses and permits. The patient is a registered inpatient in an acute care hspital and the specialized services are nt available in that hspital. The patient is transprted t the nearest prvider f the specialized medical service that is the nearest ne with the required capabilities. The patient s cnditin wuld be jepardized in the absence f medically-trained persnnel r ther means f transprtatin is cntraindicated (fr example, thugh nt all inclusive: patient is bed-cnfined; patient has full bdy cast). Ambulance Services fr Deceased Member Ambulance services are cnsidered medically necessary if the patient is legally prnunced dead after the ambulance was called, but befre pickup, r death ccurs en rute t the hspital.
3 Ambulance services are cnsidered nt medically necessary if the patient is legally prnunced dead befre the ambulance was called. Related Plicies Nne Plicy Guidelines In all cases, the apprpriate dcumentatin must be kept n file and upn request, presented t the plan. The presence r absence f a physician s rder fr ambulance transprt des nt necessarily prve r disprve whether the service was medically necessary. Nte: This plicy prvides medical guidelines that are apprpriate fr the majrity f individuals wh need ambulance and medical transprt services in bth emergency and nnemergency situatins. Unique clinical circumstances may justify individual cnsideratin fr cverage, based n a review f applicable medical recrds. Descriptin Ambulance and medical transprt services invlve the use f specially designed and equipped vehicles t prvide transprtatin fr patients wh are injured r have acute medical cnditins. These services may invlve grund, air, r sea transprt in bth emergency and nnemergency situatins. Scpe Medical plicies are systematically develped guidelines that serve as a resurce fr Cmpany staff when determining cverage fr specific medical prcedures, drugs r devices. Cverage fr medical services is subject t the limits and cnditins f the member benefit plan. Members and their prviders shuld cnsult the member benefit bklet r cntact a custmer service representative t determine whether there are any benefit limitatins. This medical plicy des nt apply t Medicare Advantage. Benefit Applicatin All devices are cnsidered an integral part f the ambulance and medical transprt services and n additinal benefits are prvided fr reusable r dispsable devices r supplies. Benefits are nt prvided fr medical transprt t nursing facilities, physician ffices, dialysis centers r patient hmes. Cnsult the member benefit bklet t determine cverage fr ambulance transprt services. Sme Plans ffer riders fr air r sea ambulance services. If a member r grup des nt accept this rider, the Plan may cnsider reimbursement in these situatins up t the limits f the grund ambulance benefits. If a life-supprt ambulance is used, the equipment must als be used fr it t be cvered.
4 Ratinale Nne References Nne Cding Cdes Number Descriptin Nn-emergency transprtatin, cde range HCPCS A0140 Nn-emergency transprtatin and air travel (private r cmmercial) intrastate r interstate A0426 Ambulance service, advanced life supprt, nnemergency transprt, level 1 (ALS 1) A0428 Ambulance service, basic life supprt, nnemergency transprt, (BLS) A0429 Ambulance service, basic life supprt, emergency transprt A A0431 Ambulance service, cnventinal air services, transprt, ne way (fixed wing) A0431 Ambulance service, cnventinal air services, transprt, ne way (rtary wing) A0434 Specialty care transprt (SCT) A0435 Fixed wing air mileage, per statute mile A0436 Rtary wing air mileage, per statute mile A0999 Unlisted ambulance service Type f Medical Service Place f Service Inpatient Hme Physician's Office Appendix N/A Histry Date Reasn 07/12/11 New Plicy - Add t Administrative sectin. Held fr prvider 90-day ntificatin; plicy effective date December 1, /20/12 Replace Plicy. Reviewed withut literature review. Minimal rewriting fr clarity. Added HCPCS cdes A0140 Nnemergency transprtatin and air travel (private r cmmercial) intrastate r interstate and A0434 Specialty care transprt, Plicy statements unchanged.
5 09/11/12 Replace plicy. Plicy Guidelines sectin updated with statement t allw use f clinical judgment in special circumstances. Added: Nte: This plicy prvides medical guidelines that are apprpriate fr the majrity f individuals wh need ambulance and medical transprt services in bth emergency and nnemergency situatins. Unique clinical circumstances may justify individual cnsideratin fr cverage, based n review f applicable medical recrds. Plicy statement unchanged. 07/24/13 Replace plicy. Plicy reviewed. Minr edits and refrmatting fr clarificatin and readability. Plicy statement unchanged. 01/30/14 Minr update. HCPCS cdes A0426 and 0428 added t the cding sectin; these already appear n the RMN list and shuld be listed. Scpe sectin updated with language indicating this plicy is nt applicable t Medical Advantage. 06/19/14 Annual Review. Plicy reviewed withut literature review. Minr refrmatting fr readability. Plicy statement unchanged. All HCPCS remved with the exceptin f A0140, A0426, A0428, A0430- A0431 and A0999 they d nt suspend fr review. 04/24/15 Annual Review. Minr frmatting changes made fr reading clarity. HCPCS cdes A0434-A0436 added t the plicy; these had been inadvertently remved and shuld be listed. Disclaimer: This medical plicy is a guide in evaluating the medical necessity f a particular service r treatment. The Cmpany adpts plicies after careful review f published peer-reviewed scientific literature, natinal guidelines and lcal standards f practice. Since medical technlgy is cnstantly changing, the Cmpany reserves the right t review and update plicies as apprpriate. Member cntracts differ in their benefits. Always cnsult the member benefit bklet r cntact a member service representative t determine cverage fr a specific medical service r supply. CPT cdes, descriptins and materials are cpyrighted by the American Medical Assciatin (AMA) Premera All Rights Reserved.