Clinical UM Guideline
Subject: Ambulance Services: Ground; Non-Emergent
Guideline #: CG-ANC-06 Publish Date: 07/06/2022
Status: Reviewed Last Review Date: 05/12/2022
Description

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. Transfer from an acute care facility to an individual’s home or a skilled nursing facility is required.

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 for all other indications including, but not limited to the following:

  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.
Coding

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:

HCPCS

 

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-10 Diagnosis

 

 

All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

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.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Emergency Physicians. Policy Statements. Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/policy-compendium.pdf. Accessed on April 8, 2022.
  2. First Coast Service Options, Inc. Local Coverage Determination for Emergency and Non-Emergency Ground Ambulance Services (L37697). Revised 11/28/2019. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on April 8, 2022.
  3. National Association of EMS Physicians. Position Statement: Equipment for ground ambulances. 2014. Available at: https://naemsp.org/resources/position-statements/equipment-and-devices/. Accessed on April 8, 2022.
  4. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 01/01/2020. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on April 8, 2022.
  5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 07/29/2021. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on April 8, 2022.
  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.
Index

Ambulance
Non-Emergency Ambulance Transport

History

Status

Date

Action

Reviewed

05/12/2022

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

Reviewed

05/13/2021

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

Reviewed

05/14/2020

MPTAC review. Updated References section.

Revised

06/06/2019

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

Reviewed

07/26/2018

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

Revised

08/03/2017

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

Reviewed

05/04/2017

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

Reviewed

05/05/2016

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

Reviewed

05/07/2015

MPTAC review. Updated References.

New

05/15/2014

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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