Coverage Policy Manual
Policy #: 2022032
Category: Medicine
Initiated: October 2022
Last Review: August 2023
  Air Ambulance
Description:
Air ambulance transport services utilizing specially designed and equipped airplanes or helicopters are important in providing rapid medical care and transport of ill or injured patients. These air medical services may be involved in a primary response—transporting a patient from an original scene to the nearest facility capable of providing the medical care required, or a secondary response—involving an interfacility transport due to the patient's need for continuing care or a higher level of care than is available at the original facility.
 
Air ambulance providers must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits.
Policy/
Coverage:
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions for air medical transport.
  
Effective May 2023
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Emergency Air Ambulance Transport:
 
A. Emergency air ambulance transport from site of accident, injury, or illness meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when the patient is in critical condition and/or has unstable vital signs, respiratory status, or cardiac status, including but not limited to ONE of the following conditions:
 
    • Intracranial bleeding requiring emergent intervention;
    • Cardiogenic shock;
    • Acute myocardial infarction requiring emergent intervention;
    • Burns requiring immediate treatment in a Burn Center;
    • Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;
    • Multiple severe injuries;
    • Life-or limb threatening trauma;
    • Transplants;
    • High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus) ;
    • Life-threatening pregnancy condition [e.g., eclampsia, placental abruption, hemorrhage;
    • Life or limb threatening hemorrhage or vascular occlusion/dissection;
    • Resuscitation from cardiopulmonary arrest;
    • Poisoning or overdose with respiratory crisis;
    • Respiratory crisis (e.g., status asthmaticus, respiratory arrest, acute airway obstruction, etc.);
    • Cardiac arrhythmia (heart block, ventricular tachycardia/fibrillation, SVT) with decompensation (hypotension, angina, CNS changes, etc.);
    • Shock/hypotension life-threatening;
 
AND
 
ONE of the following:
 
    • The point of pick-up is inaccessible by land vehicle, or ground ambulance transport is precluded due to adverse weather, terrain and/or road conditions (e.g., flooding, ice, or snow); OR
    • Transportation by ground ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health due to the time or distance.
 
 
B. Emergency air ambulance transport services from a Health Care Facility/Hospital Emergency Department or Inpatient Setting meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient is in critical condition, has unstable vital signs, unstable respiratory or cardiac status, including but not limited to ONE of the following conditions:
        • Intracranial bleeding requiring emergent intervention;
        • Cardiogenic shock;
        • Acute myocardial infarction requiring emergent intervention;
        • Burns requiring immediate treatment in a Burn Center;
        • Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;
        • Multiple severe injuries;
        • Life-threatening trauma;
        • Transplants;
        • High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus); AND
    • The patient requires acute medical or surgical intervention(s) that the transferring facility cannot provide; AND
    • The patient is being transferred to the nearest equivalent or higher level of acuity inpatient facility unless the nearest appropriate hospital is on divert, has no available beds or accepting physician, or the air ambulance cannot land; AND
    • Transportation by ground ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health due to the time, or distance.
 
 
C. Emergency air ambulance meets member benefit certificate primary coverage criteria for a deceased individual when either:
 
    • the member was pronounced dead while in route to facility; OR  
    • the member was pronounced dead after the ambulance was dispatched but prior to arrival at scene.
 
 
 
Non-Emergency Air Ambulance Transport:
 
A. Non-emergency air ambulance medical transportation from a Health Care Facility/Hospital Emergency Department or Inpatient Setting to an equivalent or higher level of acuity facility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient requires acute inpatient care; AND
    • The patient requires services that are unavailable at the originating facility; AND
    • The receiving hospital is the nearest one with the required capabilities; AND
    • The patient cannot be safely discharged from inpatient setting; AND
    • The patient cannot be safely transported using commercial air transport; AND
    • Ground ambulance transport is precluded due to adverse weather, terrain and/or road conditions (e.g., flooding, ice, or snow).
 
 
B. Non-emergency following stabilization. Air ambulance medical transportation from a Health Care Facility/Hospital Emergency Department or Inpatient Setting to an equivalent or higher level of acuity facility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient has arrived at the Health Care Facility/Hospital Emergency Department or Inpatient Setting by emergent transport; AND
    • The patient has received sufficient care to become stabilized; AND
    • The stabilized patient cannot safely travel to the receiving Health Care Facility/Hospital Emergency Department or Inpatient Setting by any other means.
   
Air ambulance medical transportation meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for the following indications:
 
    • To support continuity of care - where previous treatment involving the current or related condition occurred in a facility that is further away than the closest capable facility, and transport via ground ambulance or commercial means is not an option and will not be an option for at least two weeks.
    • When there is documentation or Attending Physician attestation that the transported patient requires a specialized service that cannot be provided by a closer facility.
    • The patient will likely require either acute care or rehabilitation for over 3 months and appropriate care is available closer to support system.
    • Patient is being returned to original hospital after initial transport for specialized care and continued inpatient hospitalization is likely to be required for at least an additional two weeks.
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Emergency air ambulance for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of the air ambulance does not meet member benefit certificate primary coverage criteria.
 
For members with contracts without primary coverage criteria, emergency air ambulance for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of the air ambulance is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Non-emergency air ambulance medical transportation provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility, including situations where long distances exist between the transferring and receiving facilities, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, non-emergency air ambulance medical transportation provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility, including situations where long distances exist between the transferring and receiving facilities, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Air Ambulance transport for all other indications and situations not described above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, Air Ambulance transport for all other indications and situations not described above as covered is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective October 2022 through April 2023
 
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions for air medical transport.
 
Effective January 1, 2023, Prior Authorization is required for ALL Non-Emergency Air Ambulance Transport Services
 
As per Arkansas Code § 23-99-1107, no prior authorization for transport services shall be required when the requested transportation is in response to the presence of a medical emergency.
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Emergency Air Ambulance Transport:
 
A. Emergency air ambulance transport from site of accident, injury, or illness meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when the patient is in critical condition and/or has unstable vital signs, respiratory status, or cardiac status, including but not limited to ONE of the following conditions:
 
    • Intracranial bleeding requiring emergent intervention;
    • Cardiogenic shock;
    • Acute myocardial infarction requiring emergent intervention;
    • Burns requiring immediate treatment in a Burn Center;
    • Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;
    • Multiple severe injuries;
    • Life-or limb threatening trauma;
    • Transplants;
    • High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus) ;
    • Life-threatening pregnancy condition [e.g., eclampsia, placental abruption, hemorrhage;
    • Life or limb threatening hemorrhage or vascular occlusion/dissection
    • Resuscitation from cardiopulmonary arrest;
    • Poisoning or overdose with respiratory crisis;
    • Respiratory crisis (e.g., status asthmaticus, respiratory arrest, acute airway obstruction, etc.);
    • Cardiac arrhythmia (heart block, ventricular tachycardia/fibrillation, SVT) with decompensation (hypotension, angina, CNS changes, etc.);
    • Shock/hypotension life-threatening;
 
AND
 
ONE of the following:
 
    • The point of pick-up is inaccessible by land vehicle, or ground ambulance transport is precluded due to adverse weather, terrain and/or road conditions (e.g., flooding, ice, or snow); OR
    • Transportation by ground ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health due to the time or distance.
 
 
B. Emergency air ambulance transport services from a Health Care Facility/Hospital Emergency Department or Inpatient Setting meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient is in critical condition, has unstable vital signs, unstable respiratory or cardiac status, including but not limited to ONE of the following conditions:
      • Intracranial bleeding requiring emergent intervention;
      • Cardiogenic shock;
      • Acute myocardial infarction requiring emergent intervention;
      • Burns requiring immediate treatment in a Burn Center;
      • Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit;
      • Multiple severe injuries;
      • Life-threatening trauma;
      • Transplants;
      • High-risk pregnancy (high risk of preterm delivery or high medical risk to the mother or fetus); AND
    • The patient requires acute medical or surgical intervention(s) that the transferring facility cannot provide; AND
    • The patient is being transferred to the nearest equivalent or higher level of acuity inpatient facility unless the nearest appropriate hospital is on divert, has no available beds or accepting physician, or the air ambulance cannot land; AND
    • Transportation by ground ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health due to the time, or distance.  
 
 
C. Emergency air ambulance meets member benefit certificate primary coverage criteria for a deceased individual when either:
 
    • the member was pronounced dead while in route to facility; OR  
    • the member was pronounced dead after the ambulance was dispatched but prior to arrival at scene.
 
 
Any situations not meeting the criteria for emergency air ambulance transport from site of accident or from Health Care Facility/Hospital Emergency Department or Inpatient Setting are considered non-emergency situations and require prior authorization.
 
Non-Emergency Air Ambulance Transport:
 
D. Non-emergency air ambulance medical transportation from a Health Care Facility/Hospital Emergency Department or Inpatient Setting to an equivalent or higher level of acuity facility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient requires acute inpatient care; AND
    • The patient requires services that are unavailable at the originating facility; AND
    • The receiving hospital is the nearest one with the required capabilities; AND
    • The patient cannot be safely discharged from inpatient setting; AND
    • The patient cannot be safely transported using commercial air transport; AND
    • Ground ambulance transport is precluded due to adverse weather, terrain and/or road conditions (e.g., flooding, ice, or snow).
 
 
E. Non-emergency following stabilization.  Air ambulance medical transportation from a Health Care Facility/Hospital Emergency Department or Inpatient Setting to an equivalent or higher level of acuity facility meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when ALL the following criteria are met:
 
    • The patient has arrived at the Health Care Facility/Hospital Emergency Department or Inpatient Setting by emergent transport; AND
    • The patient has received sufficient care to become stabilized; AND
    • The stabilized patient cannot safely travel to the receiving Health Care Facility/Hospital Emergency Department or Inpatient Setting by any other means.
 
 
F. Air ambulance transport for patients seeking hospice care closer to home and for any unusual or uncommon circumstances involving frequent or recurrent air transport must be reviewed for appropriateness by the prior authorization services Medical Director.
 
Prior authorized air ambulance request may be submitted and reviewed for additional circumstances not detailed above.  An authorized Medical Director may approve services based on the individual’s needs to manage the overall care of the member, including but not limited to:
 
    • Support continuity of care - where previous treatment involving the current or related condition occurred in a facility that is further away than the closest capable facility, and transport via ground ambulance or commercial means is not an option and will not be an option for at least two weeks
    • When there is documentation or Attending Physician attestation that the transported patient requires a specialized service that cannot be provided by a closer facility.
    • The patient will likely require either acute care or rehabilitation for over 3 months and appropriate care is available closer to support system
    • Patient is being returned to original hospital after initial transport for specialized care and continued inpatient hospitalization is likely to be required for at least an additional two weeks
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Emergency air ambulance for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of the air ambulance does not meet member benefit certificate primary coverage criteria.
 
For members with contracts without primary coverage criteria, emergency air ambulance for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of the air ambulance is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Non-emergency air ambulance medical transportation provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility, including situations where long distances exist between the transferring and receiving facilities, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, non-emergency air ambulance medical transportation provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility, including situations where long distances exist between the transferring and receiving facilities, is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Air Ambulance transport for all other indications and situations not described above as covered does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, Air Ambulance transport for all other indications and situations not described above as covered is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Rationale:
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 the individual’s illness or injury, non-emergency medical transport of an individual to another location to obtain medically needed specialized services. An air ambulance may be a specially equipped aircraft such as a helicopter or airplane. Water ambulances are specially equipped boats. 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.
 
In general, an emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
 
    • Placing the physical or mental health of the individual afflicted with such condition or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
    • Serious impairment to such individual's bodily functions; or
    • Serious dysfunction of any bodily organ or part of such individual.
 
Examples of medical emergencies may include illness or injury such as severe chest pains that might indicate a heart attack, slurred speech or weakness that might indicate an acute stroke, fracture, hemorrhaging, poisoning, major burns, loss of consciousness or respiratory accidents, convulsions, shock and other acute conditions.
 
A 2020 retrospective study by Stewart and colleagues compared the outcomes of transport between helicopter transport and ground transport for inter-facility transfer of persons with trauma to tertiary trauma centers. Looking at the records of 9880 people who had been initially seen at a non-tertiary trauma center, but were then transferred to a tertiary trauma center, the authors reported on mortality at 72 hours and within the first 2 weeks after arriving at the tertiary trauma center. For those transferred by helicopter, the mean distance between the facilities was 96.7 miles with a mean distance of 69.9 miles for those transferred by ground ambulance. The helicopter transport group showed a decreased 72 hour mortality only for the individuals transferred less than 90 miles. There were no significant differences in mortality for helicopter transport greater than 90 miles, and no significant differences in mortality at 2 weeks for either transport modality.
 
In 2021, Kunte and colleagues reported on whether air or ground transport led to faster delivery times in interhospital transfer and direct-from-scene transfer of individuals with ischemic stroke to a comprehensive stroke center. In this retrospective review, there were four cohorts: transfer air (n=47), transfer ground (n=68), scene air (n=40) and scene ground (n=50). Three time periods were looked at within the transport process: alarm to emergency medical services (EMS) arrival, EMS arrival to EMS departure, and EMS departure to comprehensive stroke center arrival. Median alarm to EMS arrival time was 27.5 minutes for transfer air, 15.5 minutes for transfer ground, 22 minutes for scene air, and 10 minutes for scene ground. Total on scene time was represented by EMS arrival to EMS departure.  Median EMS arrival to EMS departure time was 13 minutes for transfer air, 14 minutes for transfer ground, 7.5 minutes for scene air, and 12 minutes for scene ground. In order to evaluate EMS transfer time not associated with actual travel time, the authors measured the amount of time it took EMS to respond to alarms and prepare the individual for transfer. Those in the transfer cohort had a median alarm to EMS departure of 39 minutes versus 31 minutes for those in the scene cohort. Also in the transfer cohort, transfer air had a median alarm to EMS departure of 44 minutes versus 36 minutes for transfer ground. For those being transported from the scene, scene air median alarm to EMS departure time was 37.5 minutes compared to 25 minutes for scene ground noting air transport had longer EMS time before departure compared to ground transport. Modified Rankin score was used at 90 days after treatment to quantify functional outcomes. There were no significant differences in scores between the groups. The authors did not report whether outcomes were improved. In transporting individuals either between facilities or from scenes, some variables cannot be accounted for such as weather and traffic at the time of transfer.
 
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through July 2023. No new literature was identified that would prompt a change in the coverage statement.
CPT/HCPCS:
A0430Ambulance service, conventional air services, transport, one way (fixed wing)
A0431Ambulance service, conventional air services, transport, one way (rotary wing)
A0435Fixed wing air mileage, per statute mile
A0436Rotary wing air mileage, per statute mile
S9960Ambulance service, conventional air service, nonemergency transport, one way (fixed wing)
S9961Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)
References: American College of Emergency Physicians.(2018) Appropriate and Safe Utilization of Helicopter Emergency Medical Services (September 2018). Policy Statements. Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/policy-compendium.pdf. Accessed on October 5, 2021.

American College of Emergency Physicians.(2018) Emergency Medical Services Interfaces with Health Care Systems (February 2018). Available at: https://www.acep.org/globalassets/new-pdfs/policy-statements/policy-compendium.pdf. Accessed on October 5, 2021.

American College of Surgeons; Committee on Trauma; American College of Emergency Physicians; National Association of EMS Physicians; Pediatric Equipment Guidelines Committee; American Academy of Pediatrics.(2009) Equipment for ambulances. Bull Am Coll Surg. 2009; 94(7):23-29.

Doucet J, Bulger E, Sanddal N, et al.(2013) Appropriate use of helicopter emergency medical services for transport of trauma patients: guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma Acute Care Surg. 2013; 75(4):734-741.

Funder KS, Rasmussen LS, Lohse N, et al.(2017) The impact of a physician-staffed helicopter on outcome in patients admitted to a stroke unit: a prospective observational study. Scand J Trauma Resusc Emerg Med. 2017; 25(1):18.

Galvagno SM Jr, Haut ER, Zafar SN, et al.(2012) Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012; 307(15):1602-1610.

Kunte SA, Anderson D, Brown-Espaillat K, Froehler MT.(2021) Total transfer time for ground vs. air transport for interhospital and scene transfers of acute stroke patients. J Stroke Cerebrovasc Dis. 2021; 30(6):105704.

Lyng J, Adelgais K, Alter R, et al.(2021) Recommended essential equipment for basic life support and advanced life support ground ambulances 2020: A Joint Position Statement. Prehosp Emerg Care. 2021; 25(3):451-459.

Medicare Benefit Policy Manual.(2018) Chapter 10 - Ambulance Services. April 13, 2018. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c10.pdf. Accessed on October 5, 2021.

Nolan B, Haas B, Tien H, et al.(2020) Causes of delay during interfacility transports of injured patients transported by air ambulance. Prehosp Emerg Care. 2020; 24(5):625-633.

Palmetto GBA.(2021) 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 October 5, 2021.

Stewart K, Garwe T, Oluborode B, et al.(2021) Association of interfacility helicopter versus ground ambulance transport and in-hospital mortality among trauma patients. Prehosp Emerg Care. 2021; 25(5):620-628.

Thomson DP, Thomas SH;(2007) 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.
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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