Clinical UM Guideline


Subject:Ambulance Services: Ground
Guideline #:  CG-ANC-01Current Effective Date:  04/15/2014
Status:ReviewedLast Review Date:  02/13/2014

Description

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:

Clinical Indications

Medically Necessary:

The use of ground ambulance services is considered medically necessary when the following criteria are met (1, 2, AND 3 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. Any of the following circumstances exists:
    1. Transportation from the scene of a life-threatening accident or emergency to the nearest hospital or physician's office with appropriate facilities for treatment of an individual's illness or injury is required; or
    2. 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 (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides; or
    3. Transfer from an acute care facility to an individual's home or a skilled nursing facility is required.

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.

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:

  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 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.

HCPCS 
A0225Ambulance service, neonatal transport, base, rate, emergency transport, one way
A0380BLS mileage (per mile)
A0390ALS mileage (per mile)
A0425Ground mileage, per statute mile
A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)
A0427Ambulance service, advanced life support, emergency transport, Level 1 (ASL1-Emergency)
A0428 Ambulance service, basic life support, non-emergency transport (BLS)
A0429Ambulance service, basic life support, emergency transport (BLS-Emergency)
A0432Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers
A0433Advanced life support, Level 2 (ASL2)
A0434Specialty care transport (SCT)
A0998Ambulance response and treatment, no transport
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
Discussion/General Information

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.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Emergency Physicians. Guidelines for Ambulance Diversion (1999, reaffirmed 2012). Available at: http://www.acep.org/practres.aspx?id=29080. Accessed on December 11, 2013.
  2. American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed 2008). Available at: http://www.acep.org/practres.aspx?id=29078. Accessed on December 11, 2013.
  3. 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 December 11, 2013.
  4. Cahaba Government Benefit Administrators®. Local Coverage Determination for Transportation Services: Ambulance (L30022). Revised 08/01/2012. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 22, 2013.
  5. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L32252). Revised 06/20/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 22, 2013.
  6. Palmetto GBA. Local Coverage Determination for Ambulance Services (L31604). Revised 07/11/2013. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on December 22, 2013.
  7. 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

Emergency Transport

History
StatusDateAction
Reviewed02/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References.
Reviewed02/14/2013MPTAC review. Updated References.
Reviewed02/16/2012MPTAC review. No change to Clinical Indications.
Reviewed02/17/2011MPTAC review. Updated Rationale and Reference sections.
Revised02/25/2010MPTAC 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.
Reviewed02/26/2009MPTAC review. No change to position statement. Updated Reference section.
Revised02/21/2008MPTAC review. Removed the term "Life threatening" from the medically necessary portion of section II. Air or Water Ambulance Services. Updated Reference section.
Revised03/08/2007MPTAC 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.
Revised03/23/2006MPTAC review. 
New12/01/2005MPTAC initial document development.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem Midwest

02/11/2004

MA-034Air Ambulance Services
Anthem Virginia

10/15/2004

 Ambulance and Medical Transport
Anthem Maine

n/a

 Ambulance Benefit Detail