Clinical UM Guideline

This document addresses the use of ground ambulances in non-emergency situations. An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions.

Note: Wheelchair vans or other such vehicles are not equipped as ambulances and are not addressed in this document.

Note: Please see the following related documents for additional information.

• CG-ANC-04 Ambulance Services: Air and Water
• CG-ANC-05 Ambulance Services: Ground; Emergent
• CG-ANC-07 Inpatient Interfacility Transfers

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

Medically Necessary:

Non-emergency ground ambulance services are considered medically necessary when the following criteria are met (A, B, and C 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 (for example bed-confined [unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair]); and
3. Either of the following circumstances exists:
   1. 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 (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides; or
   2. The requested transfer is from an acute care facility to an individual’s home or a skilled nursing facility.

Mileage associated with the ground ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate location.

Non-emergency ground ambulance services are considered medically necessary if the ground ambulance provider responds to a call and provides medically necessary treatment, but the ambulance transport is not completed.

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:

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.

Not Medically Necessary:

Non-emergency ground ambulance services are considered not medically necessary when the above criteria are not met and for all other indications.

Mileage in excess of the distance from the trip origin to the nearest appropriate location is considered not medically necessary.

This document describes clinical studies and expert recommendations, and explains when ambulance transport for non-emergency instances is clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Non-emergency ground ambulance services involve transport by a specially equipped vehicle when a person’s medical condition makes other forms of transportation unsafe. These ambulances carry medical equipment and trained staff who can provide care during the trip. This document does not apply to wheelchair vans or air or water ambulances. The service may be appropriate when a person cannot safely travel by car or wheelchair van due to a serious medical condition, and when transportation is needed to receive medical care that is not available at their current location.

What the Studies Show

A ground ambulance is a vehicle equipped with medical tools and supplies to provide care during transport. This may include equipment to help with breathing, monitor the heart, give medications, prevent infection, control bleeding, or to support people who cannot move safely on their own. Trained staff can provide treatment during the trip if needed.

Non-emergency ambulance transport may be needed when a person cannot get out of bed without help, cannot walk, cannot sit in a chair or wheelchair, or has a condition such as severe dizziness that makes it unsafe to sit upright. In these cases, other types of transportation could put the person’s health at risk. Ambulance transport can also be used to move a person between medical facilities or to return home after hospital care, if medical needs require this level of support during travel.

When is Non-Emergency Ground Ambulance Transport Clinically Appropriate?

Non-emergency ground ambulance transport may be appropriate in these situations:

• The ambulance has the equipment and supplies needed to meet the person’s medical needs; and
• The person’s medical condition makes any other form of transportation unsafe, such as being unable to get out of bed without help, unable to walk, or unable to sit in a chair or wheelchair; and
• One of the following applies:
  • The person needs to be transported to or from a hospital, skilled nursing facility, or dialysis center to receive medically necessary tests or treatments that are not available at their current location; or
  • The person is being transferred from a hospital to their home or to a skilled nursing facility.

Reimbursement for mileage is considered appropriate only for the distance to the nearest appropriate facility.

If ambulance staff respond to a call and provide medically necessary treatment, the service may still be appropriate even if the person is not transported.

Transport for a person who has died is clinically appropriate if the above criteria were met and the person was pronounced dead during transport, upon arrival, or after the ambulance was called but before pick-up by a legally authorized professional.

When is this not Clinically Appropriate?

Non-emergency ground ambulance transport is not clinically appropriate when the criteria listed above are not met. For example, if a person can safely travel by car or wheelchair van, ambulance transport is not appropriate.

Reimbursement for mileage beyond the distance to the nearest appropriate facility is also not considered appropriate.

Non-emergency ground ambulance transport is not clinically appropriate in scenarios other than those listed above.

(Return to Description)

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.

When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

Summary

Ambulance services use specially equipped vehicles to provide emergency or non-emergency transport for medical care. Non-emergency ambulance transportation is provided when an individual cannot safely use other transportation methods due to medical limitations.

Discussion

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. 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.

While 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 a ground transportation vehicle, such as a specially equipped truck or van, but may also be a properly equipped aircraft such as a helicopter, airplane or boat. Water ambulances are specially equipped boats. This document specifically addresses only ground transportation-type ambulances.

Non-emergency medical transport via ambulance may be necessary if other forms of transportation are medically contraindicated. Examples include being unable to get up from bed without assistance, unable to ambulate, unable to sit in a chair or wheelchair or having severe vertigo causing inability to remain upright.

Government Agency, Medical Society, and Other Authoritative Publications:

1. American College of Emergency Physicians. Policy Statements. Available at: https://www.acep.org/patient-care/policy-statements. Accessed on March 6, 2026.
   • Appropriate Interfacility Patient Transfer (January 2022)
   • Emergency Medical Services Interfaces with Health Care Systems (June 2024)
   • Transfer of Patient Care Between EMS Providers and Receiving Facilities (January 2019)
2. National Association of EMS Physicians. Available at: https://naemsp.org/resources/position-statements/. Accessed on March 6, 2026.
   • Position Statement: Equipment for ground ambulances. (2013)
   • Position Statement: Recommended Essential Equipment for Basic Life Support and Advanced Life Support Ground Ambulances. (2021)
3. 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.

Ambulance
Non-Emergency Ambulance Transport

Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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