CAM 100105

Ambulance and Medical Transport Services

Category:Other   Last Reviewed:December 2019
Department(s):Medical Affairs   Next Review:September 2999
Original Date:April 1998    

Description:
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, air or sea transport in both emergency and specialty care transport situations.

Policy:
Ground emergency medical transport services are MEDICALLY NECESSARY when the following criteria are met:

  • The medical transport services must comply with all local, state and federal laws and must have all the appropriate, valid licenses and permits.
  • The ambulance or other medical transport services must have the necessary patient care equipment and supplies.
  • The patient’s condition must be such that any other form of transportation would be medically contraindicated.
  • The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of an organ transplantation, to the approved transplant facility.

In exceptional circumstances, including, but not limited to, when point of pickup is inaccessible by land vehicle, air or sea ambulance services may be MEDICALLY NECESSARY. In these circumstances, all of the criteria pertaining to ground transportation must be met, as well as the following:

  • The patient’s medical condition requires immediate and rapid ambulance transport that could not have been provided by land ambulance.
  • Great distances, limited time frames or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment, e.g., transport of a critically ill patient to an approved transplant facility with a waiting organ.
  • The patient’s condition is such that the time needed to transport a patient by land poses a threat to the patient’s health and/or life.

Specialty care medical transport services are medically necessary when the following criteria are met:

  • The medical transport services must comply with all local, state and federal laws and must have all the appropriate, valid licenses and permits.
  • The patient is in an acute care hospital and the specialized services are not available in that hospital.
  • The provider of the specialized service is the nearest one with the required capabilities. 

Effective 01/01/2020, nonemergency transport will be considered MEDICALLY NECESSARY to transfer from a precertified inpatient hospital or skilled nursing facility to a precertified lower level of care admission when the member's condition makes other forms of transportation unfeasible (e.g., mechanical ventilation, traction).  This transportation will require prior authorization according to the individual contract. 

Policy Guidelines:
Ambulance services are considered NOT MEDICALLY NECESSARY if the patient is not transported to a health care facility.

The ambulance services are considered NOT MEDICALLY NECESSARY if the patient is legally pronounced dead before the ambulance was called. The services are considered eligible for coverage if the patient is legally pronounced dead after the ambulance was called, but before pickup, or en route to the hospital
.

Coding Section

Codes Number Description
CPT No Code  
ICD-9 Procedure No Code  
ICD-9 Diagnosis No Code  
HCPCS A0429 Ambulance service, basic life support, emergency transport
  A0427 Ambulance service, advanced life support, emergency transport, level 1
  A0433 Advanced life support, level 2
  A0430-A0431; A0435-A0436 Ambulance service, conventional air services, transport, one way – code series
  A0080-A0210 Non-emergency transportation (code range)
  A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way
  A0380 BLS mileage (per mile)
  A0382-A0384 BLS disposable supplies (code range)
  A0390 ALS mileage (per mile)
  A0392-A0398 ALS disposable supplies (code range)
  A0420 Ambulance waiting time
  A0422 Ambulance oxygen and oxygen supplies, life-sustaining situation
  A0424 Extra ambulance attendant
  A0425 Ground mileage, per statute mile
  A0426  Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) 
  A0428  Ambulance service, basic life support, non-emergency transport, (BLS) 
  A0888 Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)
  A0999 Unlisted ambulance service
Type of Service Medical  

Place of Service

Inpatient/Home/Physician's Office  

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

History From 2014 Forward     

01/07/2020 

Adding Codes A0426 and A0428 to coding section. No other changes made 

12/27/2019 

Correcting typo. 

12/13/2019 

Interim review to add language related to nonemergency transport. This transport, when preauthorized, will be available effective 01/01/2020.

09/04/2019 

Annual review, no change to policy intent. 

09/10/2018 

Annual review, no change to policy intent.

09/21/2017 

Annual review, no change to policy intent. 

09/19/2016 

Annual review, no change to policy intent. 

09/14/2015 

Annual review, no change to policy intent. Added coding.

09/07/2014

Annual review, no changes made.


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