An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions.  Wheel-chair vans or other such vehicles are not so equipped and are not addressed in this document.  This document addresses the use of air or water ambulance services.

Note: For information regarding standard ground ambulance services please see CG-ANC-01 Ambulance Services: Ground

Medically Necessary:  

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

1. The ambulance must have the necessary patient-care equipment and supplies to address the needs of the individual; and
2. The individual's condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
3. The individual's condition is such that the time needed to transport by land poses a threat to the individual's survival or seriously endangers the individual's health; or the individual's location is such that accessibility is only feasible by air or water transportation; and
4. The individual is transported to the nearest hospital with appropriate facilities for treatment; and
5. There is a medical condition that is life threatening, including, but not limited to, the following:
   • Intracranial bleeding; or
   • Cardiogenic shock; or
   • Major burns requiring immediate treatment in a Burn Center; or
   • Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit; or
   • Multiple severe injuries; or
   • Transplants; or
   • Limb-threatening trauma; or
   • High risk pregnancy; or
   • Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as PTCA or fibrinolytic therapy).
     
     The use of air and water ambulance services to transport an individual from one hospital to another requires that:
     
   • The above criteria must be met, and
   • The first hospital does not have the required services and facilities to treat the individual.

The use of air and water ambulance services for deceased individuals is considered medically necessary when the above criteria are 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: 

All other uses of air and water ambulance services are considered not medically necessary, including, but not limited to, the following:

1. Transfers from one hospital to another if above criteria not met; or
2. Transfers from a hospital capable of treating an individual to another hospital primarily for the convenience of the individual or the individual's family or physician; or
3. Transportation to a hospital other than the nearest one with appropriate facilities; or
4. When land transportation is available and the time required to transport the individual by land does not endanger the patient's life or health; or
5. Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician's office or the individual's home; or
6. 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.

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. 

Ambulance transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients.  Ambulance transport may involve the movement of a patient to the nearest hospital for treatment of a patient's illness or injury, non-emergency medical transport of a patient to another location to obtain medically necessary specialized diagnostic or treatment services, or non-emergency medical transport to a hospital or to a patient's home.  An air ambulance may be a specially equipped aircraft such as a helicopter of airplane or boats. Water ambulances are specially equipped boats.

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:

• Serious jeopardy to the mental or physical health of the individual; or
• Danger of serious impairment of the individual's body functions; or
• Serious dysfunction of any of the individual's bodily organs; or
• In the case of a pregnant woman, serious jeopardy to the health of the fetus.

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.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Surgeons/ American College of Emergency Physicians/ American College of Physicians Academy of Pediatrics/ National Association of EMS physicians. Equipment for Ambulances/American College of Physicians. Equipment for Ambulances (2009). Available at: www.facs.org/trauma/publications/ambulance.pdf. Accessed on January 5, 2010.
2. American College of Emergency Physicians. Guidelines for Ambulance Diversion (1999, reaffirmed 2006). Available at: http://www.acep.org/practres.aspx?id=29080. Accessed on January 5, 2010.
3. American College of Emergency Physicians/ National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001, reaffirmed June, 2008). Available at:
   http://www.acep.org/practres.aspx?id=29078. Accessed on February 8, 2010
4. 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.

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Boat
Emergency Transport
Helicopter
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