Clinical UM Guideline
|Subject:||Ambulance Services: Ground|
|Guideline #:||CG-ANC-01||Current Effective Date:||04/15/2014|
|Status:||Reviewed||Last Review Date:||02/13/2014|
An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Wheelchair vans or other such vehicles are not so equipped and are not addressed in this document.
Note: Please see the following related document for additional information:
The use of ground ambulance services is considered medically necessary when the following criteria are met (1, 2, AND 3 must be met):
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:
Ambulance providers are required to respond to all emergency calls, but occasionally after assessment, transport is declined by the individual. In such cases ambulance services would be considered medically necessary.
Not Medically Necessary:
Use of ground ambulance services is considered not medically necessary when:
The following codes for treatments and procedures applicable to this document 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.
|A0225||Ambulance service, neonatal transport, base, rate, emergency transport, one way|
|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)|
|A0427||Ambulance service, advanced life support, emergency transport, Level 1 (ASL1-Emergency)|
|A0428||Ambulance service, basic life support, non-emergency transport (BLS)|
|A0429||Ambulance service, basic life support, emergency transport (BLS-Emergency)|
|A0432||Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers|
|A0433||Advanced life support, Level 2 (ASL2)|
|A0434||Specialty care transport (SCT)|
|A0998||Ambulance response and treatment, no transport|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2014]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2014]|
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 boats. This document specifically addresses only ground transportation-type ambulances.
In general, a medical emergency is defined as the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain that, without immediate medical attention could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to result in:
Examples of this type of illness or injury are severe chest pains that might indicate a heart attack, slurred speech or weakness that might indicate a stroke, fracture, hemorrhaging, poisoning, major burns, loss of consciousness or respiratory accidents, convulsions, shock and other acute conditions. 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.
Government Agency, Medical Society, and Other Authoritative Publications:
|Reviewed||02/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References.|
|Reviewed||02/14/2013||MPTAC review. Updated References.|
|Reviewed||02/16/2012||MPTAC review. No change to Clinical Indications.|
|Reviewed||02/17/2011||MPTAC review. Updated Rationale and Reference sections.|
|Revised||02/25/2010||MPTAC review. Removed "air and water" from title. Moved position statement addressing air and water ambulance services to new guideline CG-ANC-04. Updated Reference, Discussion, Coding, and Index sections.|
|Reviewed||02/26/2009||MPTAC review. No change to position statement. Updated Reference section.|
|Revised||02/21/2008||MPTAC review. Removed the term "Life threatening" from the medically necessary portion of section II. Air or Water Ambulance Services. Updated Reference section.|
|Revised||03/08/2007||MPTAC review. Added position to medically necessary and not medically necessary statements regarding the use of air and water ambulances when individual is declared deceased prior to arrival or en route to destination. Updated References and Coding.|
|New||12/01/2005||MPTAC initial document development.|
Last Review Date
|MA-034||Air Ambulance Services|
|Ambulance and Medical Transport|
|Ambulance Benefit Detail|