National Medical Policy

National Medical Policy Subject: Policy Number: Specialty Care Ground Transport NMP223 Effective Date*: July 2005 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 Medicare Benefit Policy Manual. Chapter 10 Ambulance Services: http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/bp102c 10.pdf Medicare Learning Network. Medicare Ambulance Services. May 2011: https://www.cms.gov/mlnproducts/downloads/ Medicare_Ambulance_Services_ICN903194.pdf Medicare Learning Network. Ambulance Fee Schedule - Ground Ambulance Services - Manualization Revision to the Specialty Care Transport (SCT) Definition. April 30, 2007. MLN Matters Number: MM5533: https://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- Specialty Care Ground Transport Aug 14 1

MLN/MLNMattersArticles/Downloads/MM5533.pd f CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10, 30-30.1.1; Implementation of Ambulance Fee Schedule and Ground Ambulance Services. Transmittal 68. March 20, 2007 http://www.nemsis.org/v2/faq/documents/cms Manual.pdf Medicare Learning Matters Network. MLN Number: MM5533. April 30, 2007. Updated June 15, 2013. Ambulance Fee Schedule - Ground Ambulance Services - Manualization Revision to the Specialty Care Transport (SCT) Definition: http://www.cms.gov/outreach-and- Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM5533.pdf Noridian Healthcare Solutions. JE Part B. Ambulance: https://med.noridianmedicare.com/web/jeb/spe cialties/ambulance Noridian Healthcare Solutions. JE Part B. A/B Ambulance ACT Questions and Answers February 20, 2014: https://med.noridianmedicare.com/web/jeb/edu cation/act/act-questions-and-answers-february- 20-2014 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. Current Policy Statement Health Net, Inc. considers specialty care ground transport medically necessary when all of the following minimum parameters are met: Specialty Care Ground Transport Aug 14 2

1. The transport involves a hospital-to-hospital transfer 2. The patient's condition is unstable, and there is immediate threat to life or function, for example: Abnormal or deteriorating neurological status Life threatening cardiac emergencies Cardiorespiratory arrest (suspected or confirmed) Severe chest pain non-responsive to conventional therapy Serious cardiac dysrhythmias non-responsive to conventional therapy Hypertensive emergencies, severe hypotension or shock Threat to maternal or fetal life Airway compromise or severe respiratory distress Multiple trauma associated with above features, or suspicion of significant injury based on mechanism 3. One or more body systems are abnormal and rapidly deteriorating in association with an acute illness or injury. 4. Continuous monitoring, ongoing care and specialized interventions are required to correct and stabilize the patient's condition, for example: Mechanical Ventilation; Multiple Monitors Cardiac Balloon Pump; External cardiac support (ventricular assist devices, etc); Any other specialized device or procedure unique to the patient s health care needs. 5. All specialized equipment and supplies appropriate to the required interventions are available at the time of the transport. 6. Staffing is required that are beyond the general scope and practice of the paramedic. Minimum required staffing includes: One currently certified EMT-Basic and one currently certified or licensed paramedic with the additional training as defined below*; or A currently certified EMT-Basic and a currently certified or licensed paramedic accompanied by at least one of the following: A Registered Nurse with special knowledge of the patient s care needs; A certified Respiratory Therapist; A licensed physician or any licensed health care professional designated by the transferring physician (if delegated to another Specialty Care Ground Transport Aug 14 3

health care professional, this individual must be competent to manage any current or anticipated complications) * Additional required training for certified/licensed paramedics - evidence of successful completion of post-paramedic training and appropriate periodic skills verification in management of patients on ventilators, 12 lead EKG and/or other critical care monitoring devices, drug infusion pumps, and cardiac and/or other critical care medications, or any other specialized procedures or devices determined at the discretion of the caring physician. 7. Patients with any of the following IV infusions (see list of further drugs in Scientific Rationale): Vasopressors Isuprel, Dobutamine, Dopamine, Epinephrine, Norepinephrine, Phenylephrine, etc.); Vasoactive Compounds - Beta Blockers, Nitroprusside, Nitroglycerine, etc.; Antiarrhythmics Pronestyl, Amiodarone, Milrinone, etc.; Fibrinolytics - tissue plasminogen activator (tpa), Retavase (Reteplase), Heparin, etc.; Tocolytics Magnesium Sulfate, Ritodrine, etc.; Blood or blood products; Any other parenteral pharmaceutical unique to the patient s special health care needs. 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 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 implementation date. ICD-9 Codes Too many to list CPT Codes N/A HCPCS Codes A0434 Specialty care transport (SCT) Specialty Care Ground Transport Aug 14 4

Scientific Rationale Update January 2011 According to some local Medicare Carriers, Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area, for example, emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care or a paramedic with additional training. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Scientific Rationale Specialty care transport is interhospital transportation of a critically injured or ill patient by a ground mobile intensive care ambulance, which is used only for maintaining specialized or intensive care treatment. It includes provision of medically appropriate supplies and services beyond the scope of the EMT-paramedic. This kind of vehicle becomes necessary when a patient s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (e.g., emergency or critical care nursing, respiratory care, cardiovascular care, or an EMT-Paramedic with additional training. The phrase "EMT-Paramedic with additional training" recognizes that a State may permit a person who is not only certified as an EMT-Paramedic, but who also has successfully completed additional education as determined by the State in furnishing higher level medical services required by critically ill or critically injured patients, to furnish a level of service that otherwise would require a health professional in an appropriate specialty care area (e.g., a physician or a nurse) to provide. The specialty units include, but are not limited to, the Emergency Department, Surgical, Medical, Cardiac, Neuro, Neonatal, and Pediatric ICUs, Operating Room, Specialty Labs (Heart Catheterization), and Obstetrical Units. The mobile intensive care unit is staffed by at least one physician or registered nurse and another person, designated by a physician, who holds a valid license or certificate to practice in a health care profession, and when at least one of the persons staffing the Mobile Intensive Care Unit is a registered nurse whose training meets or exceeds the training required for a paramedic. Typical crew configurations are RN/Paramedic teams; less frequently RN/Physician teams. Additional personnel may be added as the patient specialty/acuity dictates, such as a perfusionist or respiratory therapist. All critical care transport crew should have competence in: Needle Cricothyroidotomy Surgical Cricothyroidotomy Needle Thoracentesis Intraosseous Needle Placement 8.5 Fr. Catheter Introducer Pericardiocentesis Chest Tubes and Collection Systems Emergent Escharotomy Specialty Care Ground Transport Aug 14 5

Endotracheal Tube Changer Airway Lab/Surgical Rotations All critical care transport crew should have the following skills sets: Monitoring Systems-Invasive lines, IABP, Capnography*, Electrical Intervention, Pacing Infusion Pump System Rapid Sequence Intubation Ventilator Set -up and Operation Vehicle Radio Operations/Safety Class * Capnography is the indirect monitoring of carbon dioxide (CO2) concentrations in a patient's blood. It provides a rapid and reliable method to detect life-threatening conditions (malposition of tracheal tubes, unsuspected ventilatory failure, circulatory failure and defective breathing circuits) and to circumvent potentially irreversible patient injury. Capnography and pulse oximetry together could have helped in the prevention of 93% of avoidable anaesthesia mishaps according to the American Society of Anesthesiologists. Patients requiring critical care transport may include: Multi-System Trauma Complex Orthopedic Injury-life/limb threatening Specialized Pediatric care for a pediatric injury High-Risk Obstetrical Services Hyperbaric treatment for toxic exposure or an emergent condition Diagnostics or intervention for a neurological injury or impairment Surgical specialist for a gastrointestinal injury or disease Replantation team for an orthopedic injury Burn Center care for thermal injuries Invasive diagnostics/intervention for a cardiothoracic injury or disease Patients with the following equipment require critical care transport: Invasive Monitoring: Pulmonary Artery Catheters (Swan Ganz) Arterial Catheters/Sheaths ( A-Lines ) Central Venous Pressure Monitor (CVP) Intracranial Pressure Monitor (ICP needle) Cardiac Assist Devices: Pacemakers (transcutaneous and transvenous) Intra-Aortic Balloon Pump Ventricular Assist Device Heart Mate Specialty Care Ground Transport Aug 14 6

Extra-Corporeal Support (ECMO) 12-Lead EKG monitoring, interpretation, and intervention Specialty drug delivery: Epidural Catheters Intra-osseous lines Respiratory equipment: Ventilators (not long-term dependent) Artificial Airway (Endotracheal/nasotracheal tubes, Cricothyroidotomy) Chest Tubes Capnography Drug infusions, such as: Aggrastat Lidocaine Amiodarone Lipids Aminophylline Magnesium Sulfate Atracrium Mannitol Antibiotics Milranone Blood Products (all) Neosynephrine Brethine Nitroglycerin Bretyllium Nipride Cardizem Pitocin Dilantin Potassium (maintenance) Dopamine (maintenance) Propofol Dobutamine (maintenance) Pronestyl Epinephrine Reopro Eminase Retavase Fentanyl Sodium Bicarbonate Heparin Solu-Medrol Insulin Streptokinase Integrelin TPA Isuprel TPN Lasix Vecuronium Levophed Versed Review History July 26, 2005 Medical Advisory Council August 2007 Update no revisions January 2011 Update - no revisions September 2011 Update. Added Revised Medicare Table. No Revisions. August 2012 Update no revisions Specialty Care Ground Transport Aug 14 7

August 2013 August 2014 Update no revisions Update no revisions. Codes updated. This policy is based on the following evidence-based guidelines: 1. Warren J, Fromm Jr RE, Orr RA, et al. Society of Critical Care Medicine. Guidelines for the inter- and intrahospital transport of critically ill patients. Crit Care Med 2004 Jan; 32(1):256-262. 2. College of Physicians & Surgeons of Manitoba. Interfacility Emergency Transportation - Guideline No. 1620. 2001. References Update August 2014 1. Raspé C1, Rückert F, Metz D, et al. Inter-hospital transfer of ECMO-assisted patients with a portable miniaturized ECMO device: 4 years of experience. Perfusion. 2014 Apr 17. [Epub ahead of print] 2. Tennyson JC, Quale MR. Reduction in STEMI transfer times utilizing a municipal "911" ambulance service. Prehosp Disaster Med. 2014 Feb;29(1):50-3. doi: 10.1017/S1049023X14000016. Epub 2014 Jan 22. References Update August 2013 1. Gässler H, Ventzke MM, Lampl L, Helm M. Transport with ongoing resuscitation: a comparison between manual and mechanical compression. Emerg Med J. 2013 Jul;30(7):589-92. 2. Ong ME, Mackey KE, Zhang ZC, et al. Mechanical CPR devices compared to manual CPR during out-of-hospital cardiac arrest and ambulance transport: a systematic review. Scand J Trauma Resusc Emerg Med. 2012 Jun 18;20:39. References Update August 2012 1. 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. 2012 Apr 18;307(15):1602-10. 2. McMullan JT, Hinckley W, Bentley J, et al. Ground emergency medical services requests for helicopter transfer of ST-segment elevation myocardial infarction patients decrease medical contact to balloon times in rural and suburban settings. Acad Emerg Med. 2012 Feb;19(2):153-60. References Update September 2011 1. Prout M, Pine JR. Management of inflight medical emergencies on commercial airlines. September 13, 2010. 2. Thomas S, Judge T, Lowell MJ, MacDonald RD, et al. Airway management success and hypoxemia rates in air and ground critical care transport: a prospective multicenter study. Prehosp Emerg Care. 2010 Jul-Sep;14(3):283. References Update January 2011 1. Baird JS, Spiegelman JB, Prianti R, et al. Noninvasive ventilation during pediatric interhospital ground transport. Prehosp Emerg Care. 2009 Apr- Jun;13(2):198-202. 2. Lees M, Elcock M. Safety of interhospital transport of cardiac patients and the need for medical escorts. Emerg Med Australas. 2008 Feb;20(1):23-31 3. Lim MT, Ratnavel N. A prospective review of adverse events during interhospital transfers of neonates by a dedicated neonatal transfer service. Pediatr Crit Care Med. 2008 May;9(3):289-93. Specialty Care Ground Transport Aug 14 8

4. Orr RA, Felmet KA, Han Y, et al. Pediatric specialized transport teams are associated with improved outcomes. Pediatrics. 2009 Jul;124(1):40-8. 5. Wagner K, Sangolt GK, Risnes I, et al. Transportation of critically ill patients on extracorporeal membrane oxygenation. Perfusion. 2008 Mar;23(2):101-6. References 1. American College of Emergency Physicians. Principles of appropriate patient transfer. Annals of Emer Med 1990;19(3): 337-8. 2. Committee on Trauma of the American College of Surgeons. Interhospital transfer of patients. ACS Bulletin 1984;69(10):29-32. 3. Kissoon N. Triage and transport of the critically ill child. Critical Care Clinics 1992;8(1):37-57. 4. Harrahill M and Bartkus E. Preparing the trauma patient for transfer. J of Emerg Nursing 1990;16(1):25-8. 5. Venkataraman ST.al. Interhospital transport: a pediatric perspective. Critical Care Clinics 1992;8(3):515-23. 6. Doyle E et al. Transport of the critically ill child. British J of Hospital Medicine 1992;48(6):314-9. 7. Herkingkruse A. Interhospital transfer: how to prepare your patient. Nursing 1991;Feb:41. 8. Halpern JS. Interhospital transfer of patients. J of Emerg Nursing 1987;13(4):249-52. 9. Tompkins JM. Interhospital transport of seriously ill or injured children. Pediatric Nursing 1990;16(1):51-3. 10. Maxwell B and Miller B. Smooth the way for safe emergency transfers. RN 1988;June:34-7. 11. Day S et.al. Pediatric interhospital critical care transport: consensus of a national leadership conference. Pediatrics 1991;88(4):696-704. 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 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. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, new or revised policies require prior notice or posting on the website before a policy is deemed effective. For Specialty Care Ground Transport Aug 14 9

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. In some states, new or revised policies require prior notice or website posting before an amendment is deemed effective. 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. Specialty Care Ground Transport Aug 14 10