AIR AMBULANCE SERVICES

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1 Protocol: OTH019 Effective Date: April 11, 2012 AIR AMBULANCE SERVICES Table of Contents Page COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE... 1 BACKGROUND... 7 APPLICABLE CODES... 7 REFERENCES... 8 PROTOCOL HISTORY/REVISION INFORMATION... 8 INSTRUCTIONS FOR USE This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding coverage, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute medical advice. COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE A. Air ambulance transportation services, either by means of helicopter or fixed wing aircraft, are medically necessary if all of the following criteria are present: 1. Air ambulance transportation is provided by an Aeromedical Transport Unit; and 2. Transportation is to an Appropriate Facility for treatment; and 3. Medical Appropriateness of the situation is established; and 4. The Specific Medical Indication required immediate and rapid ambulance transportation that could not have been provided by basic or advanced life support land ambulance. Please see below for definitions of terms B. If transport by ambulance was medically necessary and appropriate, but ground ambulance service would have sufficed, payment for the air ambulance service should be the amount payable for ground transport (if less costly). C. If the air transport was medically necessary and appropriate, but the patient could have been treated at a closer hospital than the one to which the patient was transported, the air transport payment should be limited to the rate for the distance from the point of pickup to the closer hospital. Air Ambulance Services Page 1 of 8

2 D. Payment for rural air ambulance services is appropriate only when the request for transport was made by a physician or other qualified medical personnel who reasonably determined or certified that the individual s condition required air transport due to time or geographical factors. The following are considered to be personnel qualified to order air ambulance services: o Physician o Registered nurse practitioner (from the transferring hospital) o Physician s assistant (from the transferring hospital) o Paramedic or EMT (at the scene) o Trained first responder (at the scene) Terms and Coverage Criteria: 1. Aeromedical Transport Unit: An aircraft and the trained personnel designated for medical transportation, in-flight monitoring and/or treatment. This does not include security aircraft, private aircraft, media-owned aircraft, search and rescue aircraft or military aircraft that are not specifically designated for aeromedical transportation. 2. Appropriate Facility: A hospital that is capable of providing the required level and type of care for the patient s condition. The facility must also have available the type of physician or physician specialist needed to appropriately treat the patient s condition. In determining whether a particular hospital has appropriate facilities, it should be taken into account whether the necessary physicians and other relevant medical personnel are available in the hospital at the time the patient is being transported. The fact that a more distant hospital is better equipped does not mean that a closer hospital does not have appropriate facilities. Such a finding is warranted, however, if the patient s condition requires a higher level of trauma care or other specialized service available only at the more distant hospital. Air ambulance services should not be covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician s office or a patient s home. 3. Medical Appropriateness: The following situations may justify medical appropriateness: a. The medical condition is such that the length of time needed to transport is a direct threat to the patient s survival or seriously endangers the patient s health b. During transport, the patient requires critical care life support and monitoring not available from a ground ambulance service c. The patient s condition requires that time spent in transport be as short as possible d. Potential delays using ground transportation are likely to worsen the patient s condition e. The point of pickup is inaccessible by land vehicle (remote areas, weather) f. Great distances or other obstacles (i.e., heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities g. Ground travel time to the appropriate hospital greater than 30 minutes Air Ambulance Services Page 2 of 8

3 h. When the patient is ready for transport, the air ambulance should be able to deliver the patient to the appropriate hospital in a significantly shorter time than ground transportation time. i. Total air ambulance transportation time should be estimated using the following formula: 1. Air ambulance estimated time of arrival + 2. Air Ambulance transport time to hospital minutes loading/unloading time 4. Specific Medical Indications include: Intracranial bleeding or obvious skull fracture - requiring neurosurgical intervention Cardiogenic shock, excessive blood loss or need for continuous vasoactive medications Extensive burns over 20% of body surface requiring treatment in a burn center Emergency treatment in a hyperbaric oxygen unit Multiple severe injuries in patients with age < 12 or > 55 Two or more long bone fractures Penetrating injuries on the body from mid-thigh and above Amputation or near-amputation which requires timely evaluation for possible re-implantation Severe scalping or de-gloving injuries Near-drowning with signs of hypoxia or altered mental status Pediatric cold-water drowning (with or without cardiac arrest) Spinal cord or spinal column injuries with potential for neurologic injury Revised Trauma Score < 12; Glasgow Coma Scale < 10; CRAMS 8 Facial or neck injuries/burns which may result in an unstable airway requiring invasive procedures and assisted ventilation Hypothermia Respiratory or cardiac arrest within 12 hours or current respiratory failure not responsive to treatment Significant acidosis (ph < 7.2) Immediate need for organ transplantation due to severe injury Acute myocardial infarction, dissecting aneurysm, or an acute cerebrovascular accident in evolution requiring therapy or diagnostic procedures not available at the referring facility Status epilepticus Known high-risk pregnancy with a serious injury Unstable vital signs (hypotension, tachypnea) Ejection from a vehicle Fall from a height > 20 feet Pedestrian or cyclist struck by motor vehicle at > 20 mph Fail chest or pneumothorax Major pelvic fracture (unstable pelvic ring disruption, open pelvic fracture) Air Ambulance Services Page 3 of 8

4 Hospital to Hospital Transport Air ambulance transport may be appropriate for transfer of a patient from one hospital to another if all of the following criteria are met: 1. Medical appropriateness criteria (above) are satisfied; and 2. Transportation by ground ambulance would significantly endanger the patient s health; and 3. The transferring hospital does not have adequate or appropriate facilities for the condition; and 4. The receiving hospital is the nearest one with adequate or appropriate facilities for the condition; and 5. The transfer has been determined medically necessary by a physician at the medical facility requesting the transfer of the patient. Medicare does not have a National Coverage Determination or a Local Coverage Determination for Nevada specific to Air Ambulance Services. There is a Local Coverage Determination for Ambulance Services (L28235), accessed February This LCD includes the following information on air ambulances: To be covered, the ambulance service must be medically necessary and reasonable. Medical necessity is established when the beneficiary s clinical condition (an emergency) or ambulatory status are such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be utilized without endangering the individual s health, whether or not such other transportation is actually available, no payment may be made for the ambulance service. Coverage will not be allowed for ambulance services if the only documentation of medical necessity is "nonambulatory". "Nonambulatory" does not specify whether or not the beneficiary could have ridden in a car in a sitting position. Example: A quadriplegic beneficiary with an ingrown toenail does not require emergency transport. Emergency services mean services provided after the onset of a medical condition, manifesting itself by signs or symptoms of such severity (including severe pain) that the absence of immediate medical stabilization and transport, could reasonably be expected to result in any of the following: jeopardizing the beneficiary s health or life; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part. Fixed Wing (FW) Air Ambulance FW air ambulance is the transportation by a fixed wing aircraft that is certified as a fixed wing air ambulance and such services and supplies as may be medically necessary. Rotary Wing (RW) Air Ambulance RW air ambulance is the transportation by a helicopter that is certified by the FAA as a rotary wing ambulance, and such services and supplies as may be medically necessary. Air Ambulance Services Page 4 of 8

5 Rotary Wing air ambulance is furnished when the beneficiary s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the beneficiary s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g.., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle. Rural Air Ambulance Transport (RAAT) Rural Air Ambulance Transport shall be considered medically necessary when a physician or other qualified medical personnel orders or certifies the air transport service. The physician or qualified medical personnel must determine or certify that the individual's condition requires air transport due to time or geographical factors. The following should be considered to be personnel qualified to order air ambulance services: Physician, Registered Nurse practitioner, Physician's Assistant, Paramedic or EMT (at the scene) and Trained first responder (at the scene). Medical Reasonableness for Emergency Ambulance Transportation (Note that some of these situations may also justify non-emergency transportation.) Ambulance transport is indicated for emergency situations and when any other means of transport would be contraindicated (i.e., will further endanger the individual s condition significantly). Medical reasonableness is presumed if the record adequately documents one or more of the following: 1. Emergency situations such as injury resulting from an accident or illness with acute symptoms. Examples: hemorrhage, shock, chest pain, neurologic dysfunction, respiratory distress. 2. The beneficiary requires physical and/or pharmacological restraints by a professionally trained ambulance attendant. A description why restraints are required is necessary. Examples: beneficiary is violent, psychotic, convulsing or may be harmful to self or others. A simple diagnosis of senile, forgetful, Alzheimer s, etc. would not qualify. 3. A newly developed state of altered consciousness, such as unconsciousness or unresponsiveness. Claims for patients whose usual status is that of diminished consciousness should include documentation of the medical reasonableness for ambulance transport. 4. Oxygen is required by the beneficiary during transport. The administration of oxygen itself does not satisfy the requirement that a beneficiary needs oxygen. Documentation must reflect the need such as hypoxemia, syncope, dyspnea, heart attack, chest pain, respiratory distress, pulmonary edema, carbon monoxide poisoning, shock, stroke, unconsciousness, arrhythmia, airway obstruction and tachypnea. Ambulance transport is not medically necessary if the only reason for the ambulance service is to provide oxygen during transport and the beneficiary has Air Ambulance Services Page 5 of 8

6 a portable oxygen system available. It is presumed that this beneficiary can be transported by means other than ambulance. 5. Emergency measures or treatments are medically necessary and indicated for the beneficiary s condition. Examples: drugs, IV fluids, cardiopulmonary resuscitation, cardiac monitoring, oxygen, respiratory support, control of life threatening hemorrhage. The medical reasonableness for intravenous infusion would include: emergency rehydration for hypotension/shock; an IV access route for potential use of emergency drugs; an intravenous access route for actual use of indicated drugs. Note: By itself, IV fluid therapy does not establish medical reasonableness. Medical necessity for a cardiac monitor might include: chest pain; unexplained discomfort or pain in arms, neck, jaw; syncope; cardiac rhythm disturbance; dyspnea not due to known lung disease; severe respiratory distress; drug overdose with cardiotoxic drugs; pulmonary edema; serious head injury; unexplained coma/unconsciousness; hypertensive crisis; shock; electrical injury; cardiac arrest; stroke. 6. Immobilization of the beneficiary is necessary in order to prevent complications because of a fracture that has not been set. The presence of a possible compound fracture, or the presence of severe pain, requiring immobilization or pain medication, would usually indicate the need for ambulance transport. Simple upper extremity fractures or ankle injuries (without apparent complications) generally would not require an ambulance. If there is suspicion of neurologic injury and head or spine immobilization is needed, ambulance transport is indicated. 7. A transfer is made of a beneficiary between institutions for necessary services not available at the transferring institution and the beneficiary meets any of the criteria in 1-6 above. Example: Beneficiaries with cardiac disease requiring cardiac catheterization or coronary bypass, not available at the transferring institution, or a bed is unavailable at transferring institution for a beneficiary requiring emergency admission. Payment can be made only to the closest facility capable of providing the care needed by the beneficiary irrespective of whom orders the transport. The Following are Non-Covered Services: Ambulance trip to a funeral home Transfer from one residence to another (including domiciliary or nursing home) Transfer from a hospital which has appropriate facilities and staff for treatment to another hospital. Example: to accommodate patient or family preference to receive care by a personal physician or in a facility nearer home. Transportation to a free-standing dialysis facility for routine maintenance dialysis, unless the patient s condition justifies the medical necessity of the transport. The patient refuses to be transported. Air Ambulance Services Page 6 of 8

7 For Medicare and Medicaid Determinations Related to States Outside of Nevada: Please review Local Coverage Determinations that apply to other states outside of Nevada. Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage database on the Centers for Medicare and Medicaid Services Website. BACKGROUND Air ambulance services are generally associated with serious injury and/or catastrophic injuries. In these types of cases, an authorization request for air ambulance services must not delay definitive medical treatment of the patient. This guideline must always be followed for non-emergent air transport requests and for all hospital-to-hospital air transports. Rural air ambulance services are services in which the point of pickup of the individual occurs in a rural area or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg, 6725). APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the benefit document. This list of codes may not be all inclusive. HCPCS Codes A0382 A0384 A0392 A0394 A0396 A0398 A0420 A0422 A0424 A0430 A0431 A0432 Description 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 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 routing 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 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review) Ambulance service, conventional air services, transport, one way (fixed wing) Ambulance service, conventional air services, transport, one way (rotary wing) Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers. Air Ambulance Services Page 7 of 8

8 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 Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) A0999 Unlisted ambulance service REFERENCES Centers for Medicare and Medicaid Services. Palmetto GBA (01302). LCD for Ambulance Services, L Effective September 02, Revision effective 10/27/2011. Accessed February Air Medical Dispatch: Guidelines for Scene Response, National Association of Emergency Medical Services Physicians, Journal of Pre-hospital and Disaster Medicine, Vol. 7, No 1, March NAC 450B.568 Air ambulance: Restriction on transfer of patients. Accessed February Position Paper on the Appropriate Use of Emergency Air Medical Services, Association of Air Medical Services, The Journal of Air Medical Transport, September Position Paper: Guidelines for Air Medical Dispatch, National Association of EMS Physicians: D. Thompson & S. Thomas, Air Medical Services Committee. PROTOCOL HISTORY/REVISION INFORMATION Date 02/23/ /28/ /19/2010 Action/Description Corporate Medical Affairs Committee Air Ambulance Services Page 8 of 8

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