Clinical UM Guideline

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.

• CG-ANC-04 Ambulance Services: Air and Water
• CG-ANC-05 Ambulance Services: Ground; Emergent

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 (for example bed-confined [unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair]); 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. The requested transfer is from an acute care facility to an individual’s home or a skilled nursing facility.

Mileage associated with the ground ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate location.

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.

Not Medically Necessary:

Non-emergency ground ambulance services are considered not medically necessary when the above criteria are not met and for all other indications.

Mileage in excess of the distance from the trip origin to the nearest appropriate location is considered not medically necessary.

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.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

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 other forms of transportation are medically contraindicated. Examples include being unable to get up from bed without assistance, unable to ambulate, unable to sit in a chair or wheelchair or having severe vertigo causing inability to remain upright.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Emergency Physicians. Policy Statements. Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/policy-compendium.pdf. Accessed on March 14, 2023.
   • Appropriate Interfacility Patient Transfer (January 2022)
   • Emergency Medical Services Interfaces with Health Care Systems (February 2018)
   • Transfer of Patient Care Between EMS Providers and Receiving Facilities (January 2019)
2. First Coast Service Options, Inc. Local Coverage Determination for Emergency and Non-Emergency Ground Ambulance Services (L37697). Revised 11/28/2019. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 14, 2023.
3. National Association of EMS Physicians. Available at: https://naemsp.org/resources/position-statements/. Accessed on March 14, 2023.
   • Position Statement: Equipment for ground ambulances. 2014.
   • Position Statement: Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances. 2020.
4. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 01/01/2020. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 14, 2023.
5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 07/29/2021. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on March 14, 2023.
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.

Ambulance
Non-Emergency Ambulance Transport

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.