Coverage Policy Manual
Policy #: 2022033
Category: Medicine
Initiated: October 2022
Last Review: August 2023
  Ground Ambulance
Description:
Ambulance services typically involve the assessment and administration of care to an ill or injured patient by specially trained personnel and the transportation of the patient in a specially designed and equipped ground vehicle within an appropriate, safe, and monitored environment. This policy provides medical guidelines that are appropriate for the majority of individuals who need ambulance and medical transport services in both emergency and nonemergency situations. Unique clinical circumstances may justify individual consideration for coverage, based on a review of applicable medical records.
 
Ambulance services must have the necessary permits and licenses in compliance with all the local, state, and federal laws and regulations.
Policy/
Coverage:
For some contracts, this service is a contract specific benefit. Additional restrictions may apply to members with contracts with limitations or exclusions.
 
Effective March 2024
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Emergency Ground Ambulance Transport:
 
A. Emergency ground ambulance transport services 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 medical transport services must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits; AND
    • The ambulance or other medical transport services must have the necessary patient care equipment and supplies; AND
    • The patient’s condition must be such that any other form of transportation would be medically contraindicated; AND
    • Any of the following circumstances exists:
 
1. Transportation from the scene of a life-threatening accident or site of emergency to the nearest hospital with appropriate facilities for treatment of an individual’s illness or injury is required; OR
2. Transportation to or from one hospital or medical facility to another hospital or medical facility, in order to obtain emergent medically needed diagnostic or medical therapeutic services is required provided such services are unavailable at the facility where the individual initially resides. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of organ transplantation, to the approved transplant facility, unless the nearest appropriate hospital is on divert or has no available beds or accepting physician. OR
3. Transportation of an individual who has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.
 
B. Emergency ground ambulance meets member benefit certificate primary coverage policy 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 Ground Ambulance Transport/Interfacility Transfer:
 
A. Non-emergency ground ambulance medical transportation for interfacility transfer from one acute care hospital to another acute care hospital for diagnostic or therapeutic services (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services, etc.) 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 a registered inpatient and is being transferred to another facility for admission; AND
    • The services are medically necessary for the immediate care of the patient; AND
    • The services are unavailable at the originating facility; AND
    • The receiving hospital is the nearest one with the required capabilities; AND
    • The individual’s condition is such that any other form of transportation would be medically contraindicated (for example bed-confined [unable to get up from the bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair]).
 
B. Non-emergency ground ambulance medical transportation to or from a hospital or medical facility, outside of the acute care hospital setting, meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when:
 
    • The patient’s condition is such that trained ambulance attendants are required to monitor the patient’s clinical status (e.g., vital signs and oxygenation), OR
    • Treatments such as oxygen, intravenous fluids, or medications are needed, in order to safely transport the patient; OR
    • The patient is confined to bed and cannot be safely transported by any other means. (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair).
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance does not meet member benefit certificate primary coverage criteria.
 
For members with contracts without primary coverage criteria, emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Non-emergency ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility 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 ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Ground ambulance transport services 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, ground ambulance transport services for all other indications and situations not described above as covered are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective May 2023 through February 2024
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Emergency Ground Ambulance Transport:
 
A. Emergency ground ambulance transport services 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 medical transport services must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits; AND
    • The ambulance or other medical transport services must have the necessary patient care equipment and supplies; AND
    • The patient’s condition must be such that any other form of transportation would be medically contraindicated; AND
    • Any of the following circumstances exists:
 
1. Transportation from the scene of a life-threatening accident or site of emergency to the nearest hospital with appropriate facilities for treatment of an individual’s illness or injury is required; OR
 
2. Transportation to or from one hospital or medical facility to another hospital or medical facility, in order to obtain emergent medically needed diagnostic or medical therapeutic services is required provided such services are unavailable at the facility where the individual initially resides. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of organ transplantation, to the approved transplant facility, unless the nearest appropriate hospital is on divert or has no available beds or accepting physician. OR
 
3. Transportation of an individual who has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.
 
 
B. Emergency ground ambulance meets member benefit certificate primary coverage policy 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 Ground Ambulance Transport:
 
A. Non-emergency ground ambulance medical transportation from one acute care hospital to another acute care hospital for diagnostic or therapeutic services (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services, etc.) 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 a registered inpatient; AND
    • The services are medically necessary for the immediate care of the patient; AND
    • The services are unavailable at the originating facility; AND
    • The receiving hospital is the nearest one with the required capabilities
 
 
B. Non-emergency ground ambulance medical transportation to or from a hospital or medical facility, outside of the acute care hospital setting, meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when:
 
    • The patient’s condition is such that trained ambulance attendants are required to monitor the patient’s clinical status (e.g., vital signs and oxygenation), OR
    • treatments such as oxygen, intravenous fluids, or medications are needed, in order to safely transport the patient; OR
    • The patient is confined to bed and cannot be safely transported by any other means. (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair).
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance does not meet member benefit certificate primary coverage criteria.
 
For members with contracts without primary coverage criteria, emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Non-emergency ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility 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 ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Ground ambulance transport services 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, ground ambulance transport services for all other indications and situations not described above as covered are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Effective October 2022 through April 2023
 
Effective January 1, 2023, Prior Authorization is required for ALL Non-Emergency Ground Ambulance Transport Services.
  
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Emergency Ground Ambulance Transport:
 
A. Emergency ground ambulance transport services 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 medical transport services must comply with all local, state, and federal laws and must have all the appropriate, valid licenses and permits; AND
    • The ambulance or other medical transport services must have the necessary patient care equipment and supplies; AND
    • The patient’s condition must be such that any other form of transportation would be medically contraindicated; AND
    • Any of the following circumstances exists:
 
1. Transportation from the scene of a life-threatening accident or site of emergency to the nearest hospital with appropriate facilities for treatment of an individual’s illness or injury is required; OR
 
2. Transportation to or from one hospital or medical facility to another hospital or medical facility, in order to obtain emergent medically needed diagnostic or medical therapeutic services is required provided such services are unavailable at the facility where the individual initially resides. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury or, in the case of organ transplantation, to the approved transplant facility, unless the nearest appropriate hospital is on divert or has no available beds or accepting physician. OR
 
3. Transportation of an individual who has received care at a specific prior institution for a condition not normally managed at the originating facility (for example, organ transplant recipient) and return to that prior institution is needed to diagnose, manage, or treat a complication or other acute issue.
 
 
B. Emergency ground ambulance meets member benefit certificate primary coverage policy 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.
 
 
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. Any situations not meeting the criteria for emergency ground ambulance transport from scene/site of accident or from hospital/medical facility are considered non-emergency situations and require prior authorization.  
 
Non-Emergency Ground Ambulance Transport:
 
C. Non-emergency ground ambulance medical transportation from one acute care hospital to another acute care hospital for diagnostic or therapeutic services (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services, etc.) 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 a registered inpatient; AND
    • The services are medically necessary for the immediate care of the patient; AND
    • The services are unavailable at the originating facility; AND
    • The receiving hospital is the nearest one with the required capabilities
 
 
D. Non-emergency ground ambulance medical transportation to or from a hospital or medical facility, outside of the acute care hospital setting, meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes when:
 
    • The patient’s condition is such that trained ambulance attendants are required to monitor the patient’s clinical status (e.g., vital signs and oxygenation), OR
    • treatments such as oxygen, intravenous fluids, or medications are needed, in order to safely transport the patient; OR
    • The patient is confined to bed and cannot be safely transported by any other means. (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair).
 
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
Emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance does not meet member benefit certificate primary coverage criteria.
 
For members with contracts without primary coverage criteria, emergency ambulance services for transfer of a deceased individual to funeral home, morgue, or hospital when pronounced dead at the scene prior to dispatch of ground ambulance is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Non-emergency ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility 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 ground ambulance medical transportation services provided primarily for the convenience of the patient, the patient’s family/caregivers or physician, or the transferring facility is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Ground ambulance transport services 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, ground ambulance transport services for all other indications and situations not described above as covered are 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 diagnostic or treatment services.  
 
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; or
    • 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.
 
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 a medical condition causing inability to remain upright.
 
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:
A0225Ambulance service, neonatal transport, base rate, emergency transport, one way
A0425Ground mileage, per statute mile
A0426Ambulance service, advanced life support, non emergency transport, level 1 (als 1)
A0427Ambulance service, advanced life support, emergency transport, level 1 (als 1 emergency)
A0428Ambulance service, basic life support, non emergency transport, (bls)
A0429Ambulance service, basic life support, emergency transport (bls emergency)
A0432Paramedic intercept (pi), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers
A0433Advanced life support, level 2 (als 2)
A0434Specialty care transport (sct)
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). Policy Statements. 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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