National Medical Policy

National Medical Policy Subject: Policy Number: Ambulance Transportation, Non-Emergent NMP127 Effective Date*: April 2004 Updated: August 2014 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate Medicaid Manuals for coverage guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link National Coverage Determination (NCD) National Coverage Manual Citation Local Coverage Determination (LCD)* Article (Local)* X Other MLN Matters Number: SE0433: Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance Services: http://www.cms.gov/mlnmattersarticles/downlo ads/se0433.pdf Medicare Learning Network. Medicare Ambulance Services. May 2011: https://www.cms.gov/mlnproducts/downloads/ Medicare_Ambulance_Services_ICN903194.pdf CMS. Medicare Learning Network (MLN) Matters. Number MM7058. Related Change Request # 7058. Related Release date. July 30, 2010. Implementation date January 3, 2011. Ambulance Services Definition. Available at: http://www.cms.gov/mlnmattersarticles/downlo ads/mm7058.pdf Ambulance Transportation, Non-Emergent Aug 14 1

MLN Matters Number: MM8269. Related Change Request (CR) #: CR 8269. May 10, 2013. Ambulance Payment Reduction for Non- Emergency Basic Life Support (BLS) Transports to and from Renal Dialysis Facilities: http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM8269.pdf Medicare Noridian Healthcare Solutions. Ambulance: https://med.noridianmedicare.com/web/jeb/specialtie s/ambulance Medicare.gov. Ambulance Services: http://www.medicare.gov/coverage/ambulanceservices.html None Use Health Net Policy Instructions Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Very Important Note Ambulance services are covered to the extent that these types of services are generally covered by each member s benefit design as found in the Explanation of Benefits (EOC) and subject to state regulations. All requests for non-emergency ambulance services require prior authorization (PA), whereas emergency ambulance services do not. Current Policy Statement Health Net, Inc. considers non-emergency ambulance transportation medically necessary when all of the following are met: 1. The patient is bed confined* at the time of transport (Note: 'Bed confined' is not meant to be the sole criterion to be used in determining medical appropriateness. Other criteria below must also be met. * Bed confined is not synonymous with bed rest, non-ambulatory, or stretcher-bound, but is defined by all of the following: The individual is unable to get up from bed without assistance; and Ambulance Transportation, Non-Emergent Aug 14 2

The individual is unable to stand and ambulate; and The individual is unable to sit in a chair or wheelchair; and The individual is unable to tolerate any activity out of bed; and Individual can only be moved by stretcher. Examples of situations in which patients are bed-confined and cannot be moved by wheelchair, but must be moved by stretcher include: Contractures of lower extremities, in fetal position or patient unable to straighten out their body creating non-ambulatory status; or Severe generalized weakness and frailty near the ending stages of life from a terminal illness or cancer requiring traveling to hospital for radiation therapy and/or chemotherapy for metastatic disease; or Severe vertigo or truncal ataxia causing inability to remain upright; or Immobility of lower extremities (patient in spica cast, has fixed hip joints or unable to move or be moved by wheelchair); or Lower extremity paralysis patients who can not move on their own Quadriplegic patients who can not move at all below their neck Patient with polio, muscular dystrophy or multiple sclerosis who can not be transported in wheelchair Patient with dementia or a psychiatric illness where ambulance transportation is necessary for safety issues AND 2. Patient is transferred directly from one location to another and may involve any of the following scenarios: The patient is transported from home to an acute care facility for specialized services Hospital to hospital when all of the following are met: Services are not available in the hospital in which the patient is an inpatient; and The patient is transported to the nearest medical facility that can render appropriate specialized diagnostic and/or therapeutic services; and Discharge from acute care hospital to a Skilled Nursing Facility (SNF), Intermediate Care Facility or Rehabilitation Facility when the patient s condition precludes transportation by other means; or From SNF or Rehabilitation Facility to Hospital (non-emergent) when the patient cannot be transported by any other means and when the required medical service is not available at the originating facility Note: If the transport is for the purpose of receiving a service considered not to be medically appropriate, then the transport is also considered to Ambulance Transportation, Non-Emergent Aug 14 3

be not medically appropriate, even if the destination is an appropriate facility. AND 3. The patient s medical condition(s) at the time of transport contraindicates any other mode of transportation (such as automobile, taxi, wheelchair, van, invalid coach, bus, etc.) without endangering the patient's health or special handling enroute requires the attendance of medically trained personnel. Examples would include: Medical Conditions That Contraindicate Transport By Other Means (i.e., Danger To Self Or Others) MONITORING IN RESTRAINTS (FLIGHT RISK) MONITORING MONITORING MONITORING MONITORING Behavioral or cognitive risk such that patient requires an attendant to monitor for safety and assure that patient does not try to exit the ambulance prematurely Abnormal mental status; drug withdrawal; suicidal, homicidal, hallucinations, violent, Disoriented, DT s, withdrawal symptoms Psychiatric/behavioral threat to self or others Exacerbation of paranoia, or disruptive behavior Patient's physical condition is such that patient risks injury during vehicle movement despite restraints Special Handling Enroute Requiring The Attendance Of Medically Trained Personnel* AIRWAY MAINTENANCE OXYGEN DELIVERY CARDIAC STATUS ISOLATION Ventilator management / airway control / positioning / suctioning required enroute Third party assistance/attendant required to monitor, apply, administer, regulate or adjust oxygen enroute. Note: This does not apply to patients who are generally mobile and capable of selfadministration of portable oxygen in the home. Patient must require oxygen therapy and be so frail as to require assistance. Cardiac/hemodynamic monitoring required enroute Includes patients with communicable diseases or hazardous material exposure who must be isolated from public or whose medical condition must be protected from public exposure (e.g., Methicillin Resistant Staph Aureus [MRSA]/Vancomycin Resistant Enterococcus [VRE]); surgical drainage Ambulance Transportation, Non-Emergent Aug 14 4

complications. ORTHOPEDIC DEVICE MEDICATIONS Major orthopedic device, which includes body cast (spica cast), backboard, halotraction, use of pins and traction, etc. which significantly hampers transport by wheelchair, van or other vehicle and where movement needs to be controlled IV meds required enroute (does not apply to selfadministered IV medications) * Medically-trained personnel refers to individuals who have fulfilled state training and educational requirements and are certified or licensed by their respective state to provide basic life support (BLS). Note: Health Net Inc., does not consider repeat trips for a patient on the same day medically necessary because it is a duplicate service. Extra attendants or physician / hospital staff accompanying a patient enroute also are not appropriate. Note: If a patient can be transported by a vehicle other than an ambulance, it is the responsibility of the facility to ensure that the patient is transported by alternative means whenever possible. Health Net Inc., does not consider non-emergency ambulance transportation medically necessary for any of the following: Patients characterized as ambulatory, non-ambulatory, bedridden, homebound or invalid because these patients can often be transported without the use of an ambulance Need for assistance in and out of a vehicle and for transporting up or down stairs The patient does not have an illness that must be evaluated or treated All transports from home to a physician s office, an out-patient clinic, hospital or podiatrist for routine evaluation, treatment, or follow-up such as office visits to have stitches removed, follow-up visits after surgery, routine check-ups, possible fractures or to have prescriptions refilled Transportation from a skilled nursing facility/rehabilitation facility/acute care facility to the patient's home if the patient s condition is appropriate for private transportation, whether or not it is available; When other means of transportation could be utilized without endangering the individual's health, whether or not such other transportation is actually available (e.g., the patient could walk unassisted to the vehicle or could walk to the vehicle with assistance, including personal assistance or the use of a cane, crutches, walker or wheelchair) Transfer from a hospital which has appropriate facilities and staff for treatment to another hospital to accommodate patient or family preference to receive care by a personal physician or in a facility nearer home Returning physician to the transferring hospital; or Transfer for convenience of doctor, staff or family; or Routine outpatient clinic visits; or Ambulance Transportation, Non-Emergent Aug 14 5

Transportation of deceased member; or Transportation by wheelchair vans or medivans that do not meet the criteria for ambulances; or Patients discharged from inpatient and outpatient facilities to their homes because they are sufficiently recovered Transportation to a free-standing or hospital-based dialysis facility for routine maintenance dialysis because ordinarily they are not sufficiently ill enough to require ambulance transportation Patient sedated or medicated by physician that temporarily affects patient's cognitive ability or ambulation after procedure is performed (e.g., Versed given during endoscopy) CVA patient discharged home from hospital if they are able to ambulate CVA/TIA/Stroke/Heart Attack in the last few months and patient going through therapy to learn how to get around on their own Amputee of lower limbs being discharged to home from hospital or patient has had an amputation within the last few months and is going through therapy to acquire ambulation skills Round trip ambulance services utilized for those patients receiving diagnostic and/or therapeutic services which could have been reasonably brought to the patient's bedside or provided within the facility (e.g., portable x-ray) Patients transported by ambulance to a hospital for a suspected emergency condition, then treated and released, because they would no longer require the specialized service of ambulance transportation. Round trip transport from home for radiation therapy and/or chemotherapy when patient can be transported safely by other means Intra-facility transport, i.e., a transport within the certified campus of a facility Transportation of correctional inmates; or The patient refuses to be transported by any other means than ambulance Ambulance transport from a Skilled Nursing Facility to a Physician s office* for any reason Note: Health Net Inc., considers ambulance transportation services medically necessary when they are initiated through an emergency response system call and, upon examination by emergency medical personnel, the patient's condition is determined to be non-emergent but one which requires transportation by an ambulance for further evaluation. Such services do not require prior authorization (PA). Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures will be replaced by ICD-10 code sets. Health Net National Ambulance Transportation, Non-Emergent Aug 14 6

Medical Policies will now include the preliminary ICD-10 codes in preparation for this transition. Please note that these may not be the final versions of the codes and that will not be accepted for billing or payment purposes until the October 1, 2015. ICD-9 Codes Too numerous to list ICD-10 Codes Too numerous to list CPT Codes N/A HCPCS Codes A0425 A0426 A0428 A0429 Ground mileage, per statute mile Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1) Ambulance service, basic life support, non-emergency transport, (BLS) Ambulance service, basic life support, emergency transport, (BLS emergency) Scientific Rationale Update - July 2010 (2009) Centers for Medicare & Medicaid Services (CMS) has the following updated Medicare Learning Network (MLN) information regarding Roundtrip to a Physician s Office : If an Skilled Nursing Facility s (SNF s) Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance (i.e., using any other means of transport would be medically contraindicated) (see 42 CFR 409.27(c)), then the ambulance roundtrip is the responsibility of the SNF and is included in the PPS rate. The preamble to the July 30, 1999 final rule (64 Federal Register 41674-75) clarifies that the scope of the required service bundle furnished to Part A SNF residents under the PPS specifically encompasses coverage of transportation via ambulance under the conditions described above, rather than more general coverage of other forms of transportation. NOTE: Confusion sometimes arises over the issue of an ambulance roundtrip that transports an SNF resident to the physician's office, as the separate Part B ambulance benefit does not normally cover transportation to this particular setting. However, the regulations at 42 CFR 409.27(c), which describe the Part A SNF benefit s scope of coverage for ambulance transportation, incorporate by reference only the Part B ambulance benefit s general medical necessity requirement at 42 CFR 410.40(d)(1) (i.e., that transportation by any other means would be medically contraindicated), and not any of the more detailed coverage restrictions that apply under the separate Part B benefit, such as the limitation of coverage to only certain specified destinations (42 CFR 410.40(e)). Thus, if an SNF's Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance, that ambulance roundtrip would be the responsibility of the SNF. Ambulance Transportation, Non-Emergent Aug 14 7

Ambulance Service Definition Medicare Learning Network (MLN) Matters, Number MM7058, has a related change request # 7058, with the release date of July 30, 2010, and the implementation date of January 3, 2011. This is regarding Ambulance Services Definition. This incorporates the application of Basic Life Support (BLS) Emergency; Advanced Life Support Level 1 (ALS1) and Emergency and Advanced Life Support Level 2 (ALS2) information. No new policy is presented but the CR7058 updates the relevant manual section to reflect current policy. Basic Life Support (BLS) Emergency: Application: The determination to respond emergently with a BLS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider s/supplier s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary s condition (for example, symptoms) at the scene determines the appropriate level of payment. Advanced Life Support, Level 1 (ALS1) - Emergency Application: The determination to respond emergently with an ALS ambulance must be in accord with the local 911 or equivalent service dispatch protocol. If the call came in directly to the ambulance provider/supplier, then the provider s/supplier s dispatch protocol must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service. In areas that do not have a local 911 or equivalent service, then the protocol must meet, at a minimum, the standards of a dispatch protocol in another similar jurisdiction within the State or, if there is no similar jurisdiction within the State, then the standards of any other dispatch protocol within the State. Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary s condition (for example, symptoms) at the scene determines the appropriate level of payment. Advance Life Support, Level 2 (ALS2) Application: Crystalloid fluids include fluids such as 5 percent Dextrose in water, Saline and Lactated Ringer s. Medications that are administered by other means, for example: intramuscular/subcutaneous injection, oral, sublingually or nebulized, do not qualify to determine whether the ALS2 level rate is payable. However, this is not an all-inclusive list. Likewise, a single dose of medication administered fractionally (i.e., one-third of a single dose quantity) on three separate occasions does not qualify for the ALS2 payment rate. The criterion of multiple administrations of the same drug requires a suitable quantity and amount of time between administrations that is in accordance with standard medical practice guidelines. The fractional administration of a single dose (for this purpose meaning a standard or protocol dose) on three separate occasions does not qualify for ALS2 payment. In other words, the administration of 1/3rd of a qualifying dose 3 times does not equate to three qualifying doses for purposes of indicating ALS2 care. One-third of X given 3 times might = X (where X is a standard/protocol drug amount), but the same sequence does not equal 3 times X. Thus, if 3 administrations of the same drug are required to show that ALS2 care was given, each of those administrations must Ambulance Transportation, Non-Emergent Aug 14 8

be in accord with local protocols. The run will not qualify on the basis of drug administration if that administration was not according to protocol. An example of a single dose of medication administered fractionally on three separate occasions that would not qualify for the ALS2 payment rate would be the use of Intravenous (IV) Epinephrine in the treatment of pulseless Ventricular Tachycardia/Ventricular Fibrillation (VF/VT) in the adult patient. Administering this medication in increments of 0.25 mg, 0.25 mg, and 0.50 mg would not qualify for the ALS2 level of payment. This medication, according to the American Heart Association (AHA), Advanced Cardiac Life Support (ACLS) protocol, calls for Epinephrine to be administered in 1 mg increments every 3 to 5 minutes. Therefore, in order to receive payment for an ALS2 level of service based in part on the administration of Epinephrine, three separate administrations of Epinephrine in 1 mg increments must be administered for the treatment of pulseless VF/VT. A second example that would not qualify for the ALS2 payment level is the use of Adenosine in increments of 2 mg, 2 mg, and 2 mg for a total of 6 mg in the treatment of an adult patient with Paroxysmal Supraventricular Tachycardia (PSVT). According to ACLS guidelines, 6 mg of Adenosine should be given by rapid intravenous push (IVP) over 1 to 2 seconds. If the first dose does not result in the elimination of the supraventricular tachycardia within 1 to 2 minutes, 12 mg of Adenosine should be administered IVP. If the supraventricular tachycardia persists, a second 12 mg dose of Adenosine can be administered for a total of 30 mg of Adenosine. Three separate administrations of the drug Adenosine in the dosage amounts outlined in the later case would qualify for ALS2 payment. Endotracheal intubation is one of the services that qualifies for the ALS2 level of payment; therefore, it is not necessary to consider medications administered by endotracheal intubation for the purpose of determining whether the ALS2 rate is payable. The monitoring and maintenance of an endotracheal tube that was previously inserted prior to transport also qualifies as an ALS2 procedure. Scientific Rationale Initial An ambulance is a specially equipped vehicle used to transport the sick or injured. It becomes necessary when the patient is fully bed confined and has a clinical condition such that the use of any other method of transportation, such as taxi, private car, Medicar, wheelchair coach, or other type of vehicle would be contraindicated. (i.e., would endanger the patient's medical condition), whether or not such other transportation is actually available. Ambulance services are frequently the initial step in the chain of delivery of quality medical care. They involve the assessment and administration of medical care by trained personnel and transportation of patients within an appropriate, safe and monitored environment. The patient's condition at the time of the transport is the determining factor in whether a trip is necessary. The fact that the patient is elderly, has a positive medical history, or cannot care for him/herself does not establish medical necessity. The use of an ambulance service must be reasonable for the illness or injury involved. Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting individuals with acute medical conditions. The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving Ambulance Transportation, Non-Emergent Aug 14 9

emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. This should include, at a minimum, one two-way voice radio or wireless telephone. A basic life support (BLS) ambulance is one that provides ground transportation plus the equipment and staff without the use of advanced therapeutic interventions. Such basic skills include airway management (oral and nasal airways, bag-valve-mask ventilation), cardiopulmonary resuscitation (CPR), hemorrhage control, treatment for shock, fracture and spine immobilization, and childbirth assistance. Defibrillation using an automated external defibrillator (AED) is often included by many BLS systems. Services are provided by EMTs, usually certified at the basic level (EMT-B). BLS ambulances must be staffed by not less than two certified emergency medical technicians (EMTs), cardiac technicians, and/or paramedics, one of whom must be in the patient compartment. The EMTs, cardiac technicians, and paramedics must be certified by the State or local authority where the services are being furnished and be legally authorized to operate all life-saving and life-sustaining equipment on board the vehicle. The advanced life support (ALS) ambulance transport must meet the same criteria as basic life support (BLS) in addition to having specialized life sustaining equipment, which includes telecommunications equipment, at a minimum, one two-way voice radio or wireless telephone. Typical of this type of ambulance are mobile coronary care units and other ambulance vehicles that are appropriately equipped and staffed by personnel trained and authorized to administer intravenous therapy (IVs), provide anti-shock trousers, establish and maintain a patient's airway, defibrillate the heart, stabilize pneumothorax conditions and perform other advanced life support procedures or services, such as cardiac (EKG) monitoring. The term "emergency" describes a service provided after the sudden onset of a medical condition manifesting itself by acute symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in a poor clinical outcome. The term "non-emergency" refers to all scheduled transportation regardless of origin and destination. By definition, hospital discharge trips, trips to and from ESRD facilities for maintenance dialysis, to and from other outpatient facilities for chemotherapy, radiation therapy, and other diagnostic and therapeutic services, are scheduled runs, and, therefore, are considered nonemergency services. However, clinically stable patients who are ordinarily not sufficiently ill enough do not require ambulance transportation. Paramedic intercept services are advanced life support (ALS) services delivered by paramedics that operate separately from the agency that provides the ambulance transport. This type of service is most often provided for an emergency ambulance transport in which a local volunteer ambulance that can provide only basic life support (BLS) level service is dispatched to transport a patient. If the patient needs ALS services such as EKG monitoring, chest decompression, or IV therapy, another entity dispatches a paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS paramedics then provide their services to the patient. The intercept service(s) is usually provided in a rural area under a contract with one or more volunteer ambulance services and its appropriateness is based on the condition of the patient receiving the ambulance service. Review History Ambulance Transportation, Non-Emergent Aug 14 10

April 2004 June 2005 June 2007 July 2010 August 2010 December 2010 September 2011 August 2012 August 2013 August 2014 Medical Advisory Council Revised Updated no change Update. Added Ambulance transport from a Skilled Nursing Facility to a Physician s office* for any reason, as not considered medically necessary. If a SNF s Part A resident requires transportation to a physician's office and meets the general medical necessity requirement for transport by ambulance, then ambulance roundtrip is the responsibility of the SNF and is included in the Prospective Payment System (PPS) rate. Added Medicare Template and link to LCD page. Added information about Definition of Ambulance Services from MLN. Added revised Medicare Template with link to LCD and to Medicare Learning Network (MLN) Matters publication. Update. Removed information regarding Medicare members from policy statement as link in Medicare provides this information. Update No revisions Update no revisions. Update no revisions. This policy is based on the following evidence-based guidelines: 1. American College of Emergency Physicians (ACEP) Position Statement. Principles of appropriate patient transfer. Ann Emerg Med 1990;19:337-8. 2. American College of Emergency Physicians (ACEP) Position Statement. Appropriate Interhospital Patient Transfer. February 2002. 3. American College of Emergency Physicians (ACEP) Position Statement. Managed Care Principles. September, 1997. 4. American College of Emergency Physicians (ACEP) Position Statement. Principles of appropriate patient transfer. Ann Emerg Med. 1990 Mar;19(3):337-8. 5. College of Physicians & Surgeons of Manitoba. Guideline No. 1620 - Interfacility Emergency Transportation. January 2001. References Update July 2010 1. CMS Centers for Medicare & Medicaid Services. LCD for AMBULANCE Services (L28235). Palmetto GBA (01102) (Northern California). 4/29/2010. 2. CMS Centers for Medicare & Medicaid Services. LCD for AMBULANCE Services. (L28235) Palmetto GBA (01192) (Southern California). 4/29/2010. 3. CMS. Medicare Learning Network (MLN) Matters. Number MM7058. Related Change Request # 7058. Related Release date. July 30, 2010. Implementation date January 3, 2011. Ambulance Services Definition. 4. CMS. MLN Matters Number: SE0433 Revised January 29, 2009. Skilled Nursing Facility Consolidated Billing As It Relates to Ambulance Services. References - Initial 1. Stapleton ER. Basic life support cardiopulmonary resuscitation. Cardiol Clin February 2002; 20(1): 1-12 2. Rural Committee, Canadian Association of Emergency Physicians. Recommendations for the management of rural, remote and isolated emergency health care facilities in Canada. Ottawa: The Association; 1997. 42 pp. Ambulance Transportation, Non-Emergent Aug 14 11

3. Marx: Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. 4. Marinovich et al. Impact of Ambulance Transportation on Resource Use in the Emergency Department. Acad Emerg Med.2004; 11: 312-315. 5. Thompson JM, McNair N. Health care reform and emergency outpatient use of rural hospitals in Alberta, Canada. J Emerg Med 1995;13:415-21. 6. Rourke J. Small hospital medical services in Ontario. Part 2: emergency medical services. Can Fam Physician 1991;37:1720-4. 7. Dorges V, Wenzel V, Knacke P, et al: Comparison of different airway management strategies to ventilate apneic, non-preoxygenated patients. Crit Care Med 2003;31:800 3 8. Roberts: Clinical Procedures in Emergency Medicine, 4th ed. 9. Hopson LR, Hirsh E, Delgado J, et al: Guidelines for Withholding or Termination of Resuscitation in Prehospital Traumatic Cardiopulmonary Arrest: Joint Position Statement of the National Association of EMMS Physicians and the American College of Surgeons Committee on Trauma. J Amer Coll Surg 2003;196:106 112. 10. Rosen P, Barkin R, editors. Blackwell T. EMS: overview and ground transport. Emergency medicine concepts and clinical practice. St. Louis, MO: Mosby; 1998:313-23. 11. Eckstein M. Cardiac Arrest Resuscitation Evaluation in Los Angeles: CARE-LA. Ann Emerg Med May 2005;45(5):504-9 12. Liberman M, Mulder D, Lavole A, et al: Multi-Center Canadian Study of Prehospital Trauma Care. Ann Surg 2003;237:153 162. 13. Santaniello JM, Esposito TJ, Luchette FA, et al:, Mechanism of injury does not predict acuity or level of service need: field triage criteria revisited. Surgery 2003;134:698 704. 14. Thompson JM, Ratcliff MJ. Use of emergency outpatient services in a small rural hospital. Can Fam Physician 1992;38:2322-31. 15. Norman RM. Managerial dilemmas. Pediatric Emergency Care. 17(3):208-211, June 2001. 16. Fromm RE, Dellinger RP. Transport of critically ill patients. J Intensive Care Med 1992;7:223-33. 17. Committee of the American College of Critical Care Medicine. Guidelines for the transfer of critically ill patients. Crit Care Med 1993;21:931-7. 18. Thompson JM, Warnica JW. Equipping rural hospitals for cardiovascular emergencies. Can J Contin Med Educ 1992;August:23-33. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this " Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language Ambulance Transportation, Non-Emergent Aug 14 12

prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. No Medical Advice. The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. Coverage decisions are the result of the terms and conditions of the Member s benefit contract. The Policies do not replace or amend the Member s contract. If there is a discrepancy between the Policies and the Member s contract, the Member s contract shall govern. Policy Limitation: Legal and Regulatory Mandates and Requirements. The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Policy Limitations: Medicare and Medicaid. Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Ambulance Transportation, Non-Emergent Aug 14 13