Clinical UM Guideline

 

Subject: Ambulance Services: Ground; Non-Emergent
Guideline #:  CG-ANC-06 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018

Description

This document addresses the use of ground ambulances in non-emergency situations only. Wheelchair vans or other such vehicles are not equipped as ambulances and are not addressed in this document.

Note: Please see the following related documents for additional information.

Clinical Indications

Medically Necessary:

Non-emergency ground ambulance services are considered medically necessary when the following criteria are met (A, B, and C must be met):

  1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
  2. The individual’s condition must be such that any other form of transportation would be medically contraindicated; and
  3. Either of the following circumstances exists:
    1. Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides; or
    2. Transfer from an acute care facility to an individual’s home or a skilled nursing facility is required.

Non-emergency ground ambulance services are considered medically necessary if the ground ambulance provider responds to a call and provides medically necessary treatment, but the ambulance transport is not completed.

Non-emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above have been met and when either of the following is present:

  1. The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
  2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up. In these circumstances the response to call is considered medically necessary.

Not Medically Necessary:

Non-emergency ground ambulance services are considered not medically necessary when:

  1. The criteria and circumstances above have not been met; or
  2. The services are primarily for the convenience of the individual or the individual’s family or physician; or
  3. The services are for a transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead at the scene.
Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

A0380

BLS mileage (per mile)

A0390

ALS mileage (per mile)

A0425

Ground mileage, per statute mile

A0426

Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)

A0428

Ambulance service, basic life support, non-emergency transport (BLS)

A0432

Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers

A0434

Specialty care transport (SCT)

A0998

Ambulance response and treatment, no transport

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Ambulance transport services involve the use of specially designed and equipped vehicles to transport ill or injured individuals. Ambulance transport may involve the movement of an individual to the nearest hospital for treatment of an individual’s illness or injury, non-emergency medical transport of an individual to another location to obtain medically necessary specialized diagnostic or treatment services, or non-emergency medical transport to a hospital or to an individual’s home. Although wheelchair vans are specially equipped to accommodate physically challenged individuals, they do not have the proper equipment to qualify as an ambulance. Proper equipment may include ventilation and airway equipment, cardiac equipment (monitoring and defibrillation), immobilization devices, bandages, communication equipment, obstetrical kits, infection control, injury prevention equipment, vascular access equipment, and medications.

An ambulance may be either a ground transportation vehicle, such as a specially equipped truck or van, but may also be a properly equipped aircraft or boat. This document specifically addresses only ground transportation-type ambulances.

Non-emergency medical transport via ambulance may be necessary if an individual’s condition is such that any other form of transportation would be medically contraindicated such as being bed-confined (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair) and can only be moved by stretcher or having severe vertigo causing inability to remain upright.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed 2008). Available at: https://www.acep.org/#sm.0001kfe574kmeedsqo42ktwm3mqt9. Accessed on June 13, 2018.
  2. American College of Surgeons Committee on Trauma/American College of Emergency Physicians/National Association of EMS Physicians/American Academy of Pediatrics/National Association of EMS physicians. Equipment for Ambulances (2009). Available at: www.facs.org/trauma/publications/ambulance.pdf. Accessed on June 13, 2018.
  3. Cahaba Government Benefit Administrators®. Local Coverage Determination for Transportation Services: Ambulance (L34302). Revised 10/01/2015. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 13, 2018.
  4. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 03/16/2017. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 13, 2018.
  5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 05/31/2018. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 13, 2018.
  6. Thomson DP, Thomas SH; 2002-2003 Air Medical Services Committee of the National Association of EMS Physicians. Guidelines for air medical dispatch. Prehosp Emerg Care. 2007; (2):265-271.
Index

Ambulance
Non-Emergency Ambulance Transport

Document History

Status

Date

Action

Reviewed

07/26/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section.

Revised

08/03/2017

MPTAC review. Added MN statement to Clinical Indications regarding when transport is requested but not completed.

Reviewed

05/04/2017

MPTAC review. Updated Description, Discussion/General Information, and References sections. Updated formatting in Clinical Indications section.

Reviewed

05/05/2016

MPTAC review. Updated References. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated References.

New

05/15/2014

MPTAC review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.