Clinical UM Guideline
|Subject:||Ambulance Services: Ground; Non-Emergent|
|Guideline #:||CG-ANC-06||Current Effective Date:||07/07/2015|
|Status:||Reviewed||Last Review Date:||05/07/2015|
This document addresses the use of ground ambulances in non-emergency situations only. 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 documents for additional information.
The use of non-emergency ground ambulance services is considered medically necessary when the following criteria are met (1, 2, AND 3 must be met):
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:
Not Medically Necessary:
The use of non-emergency ground ambulance services is considered not medically necessary when:
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.
|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)|
|A0428||Ambulance service, basic life support, non-emergency transport (BLS)|
|A0432||Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers|
|A0434||Specialty care transport (SCT)|
|A0998||Ambulance response and treatment, no transport|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
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 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:
Non-Emergency Ambulance Transport
|Reviewed||05/07/2015||Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References.|
|New||05/15/2014||MPTAC review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.|