Clinical UM Guideline
Subject: Ambulance Services: Ground; Non-Emergent
Guideline #: CG-ANC-06 Publish Date: 06/28/2023
Status: Revised Last Review Date: 05/11/2023

This document addresses the use of ground ambulances in non-emergency situations only. 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.

Clinical Indications

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.


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:




BLS mileage (per mile)


ALS mileage (per mile)


Ground mileage, per statute mile


Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)


Ambulance service, basic life support, non-emergency transport (BLS)


Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers


Specialty care transport (SCT)


Ambulance response and treatment, no transport



ICD-10 Diagnosis



All diagnoses

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

Discussion/General Information

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. 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 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: Accessed on March 14, 2023.
  2. First Coast Service Options, Inc. Local Coverage Determination for Emergency and Non-Emergency Ground Ambulance Services (L37697). Revised 11/28/2019. Available at: Accessed on March 14, 2023.
  3. National Association of EMS Physicians. Available at: Accessed on March 14, 2023.
  4. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 01/01/2020. Available at: Accessed on March 14, 2023.
  5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 07/29/2021. Available at: Accessed on March 14, 2023.
  6. 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.

Non-Emergency Ambulance Transport







Medical Policy & Technology Assessment Committee (MPTAC) review. Revisions to MN and NMN statements regarding mileage. Revised NMN statement to remove list of non-covered indications. Updated References section. Updated Coding section to reflect when services are NMN.



MPTAC review. Updated References section.



MPTAC review. Updated Discussion/General Information and References sections. Reformatted Coding section.



MPTAC review. Updated References section.



MPTAC review. Clarification to MN statement adding examples of bed-confined. Clarification to NMN statement. Updated References section.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section.



MPTAC review. Added MN statement to Clinical Indications regarding when transport is requested but not completed.



MPTAC review. Updated Description, Discussion/General Information, and References sections. Updated formatting in Clinical Indications section.



MPTAC review. Updated References. Removed ICD-9 codes from Coding section.



MPTAC review. Updated References.



MPTAC review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.


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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