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.

Note: For information regarding air or water ambulance services please see CG-ANC-04 Ambulance Services: Air and Water

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.

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 individuals.  Ambulance transport may involve the movement of an individualto 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.  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:

• 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 December 9, 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 December 9, 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 December 9, 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.

Emergency Transport