Notification

Air Ambulance Services


Notification Issue Date: 11/02/2018

This version of the policy will become effective 01/01/2019.

This policy was updated to revise policy coverage criteria regarding Air Ambulance Services.

The following HCPCS code has been deleted from this policy:

A0999 Unlisted ambulance service

The following revenue code has been deleted from this policy:

0549 Ambulance Other Ambulance



Medical Policy Bulletin


Title:Air Ambulance Services

Policy #:12.04.03c

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

EMERGENCY AIR TRANSPORTATION

MEDICALLY NECESSARY
Emergency air ambulance services are considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  1. There is a medical condition that is life or limb threatening or that treating personnel deem to be life or limb threatening, and the individual's condition is such that the time needed to transport by land poses a threat to the individual's survival or seriously endangers the individual's health, or could result in serious impairment; or the individual's location is such that accessibility is only feasible by air transportation;
  2. The individual's condition is such that any form of transportation other than by air ambulance would be medically contraindicated;
  3. The air ambulance has the necessary equipment, supplies, and medically trained and licensed staff to address the needs of the individual;
  4. The individual is transported to the nearest hospital with appropriate facilities for treatment.
  5. The air ambulance is transporting the individual from the scene of an accident or medical emergency.

Acute Care Facility to Acute Care Air Facility Transport of a Registered Inpatient (Emergency)

Emergency air ambulance transport of a registered inpatient from one acute care facility to another acute care facility to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary when ALL of the following criteria are met:
  • The above criteria A-D must be met;
  • The necessary diagnostic and/or therapeutic services must be provided in the inpatient setting;
  • The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is admitted.
  • The necessary diagnostic and/or therapeutic services are available at the facility to which the member is being transported to.

Deceased Individuals

Air ambulance services for deceased individuals is considered medically necessary and, therefore, covered when the above criteria A-E were met and when the individual was pronounced dead while en route or upon arrival at the hospital or final destination.

NOT MEDICALLY NECESSARY
All other uses of emergency air ambulance services are considered not medically necessary and, therefore, not covered, including, but not limited to the following situations:
  1. Transfers from one hospital to another if the above criteria A-D are not met; or
  2. Transfers from a hospital capable of treating an individual to another hospital primarily for the convenience of the individual or the individual's family or healthcare professional; or
  3. Transportation to a hospital other than the nearest one with appropriate facilities; or
  4. When land transportation is available and the time required to transport the individual by land does not endanger the individual's life or health; or
  5. Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician's office or the individual's home; or
  6. 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.

NON-EMERGENCY AIR TRANSPORTATION

MEDICALLY NECESSARY
Non-emergency air ambulance services are considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  1. There is a medical condition that requires uninterrupted care and attendance by qualified medical staff during transport;
  2. The air ambulance has the necessary equipment and supplies to address the needs of the individual;
  3. The individual's condition must be such that transport cannot be provided by another means of transportation;
  4. Great distances, limited time frames, or other obstacles are involved in transporting the individual;
  5. The origin (point of pick-up) is an acute care facility (e.g., hospital, rehabilitation hospital) and is not otherwise precluded from eligibility in the member benefit contract;
  6. All of the following destination criteria are met:
    1. The destination is not precluded from eligibility in the member contract.
    2. The destination has the appropriate facilities to treat the individual’s condition.
    3. The destination must be one of the following:
      1. An acute care facility when the first hospital does not have the required services and facilities to treat the individual (e.g., trauma care, burn care).
      2. A skilled nursing facility (SNF) or acute rehabilitation facility.

Miscellaneous Items and Services

The use of extra attendants is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  1. The use of extra attendants has been prearranged with the Company.
  2. The attendants are state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.
  3. The air ambulance transport record indicates that unusual circumstances existed to necessitate the presence of extra attendants.

NOT MEDICALLY NECESSARY
All other uses of non-emergency air ambulance services are considered not medically necessary and, therefore, not covered including, but not limited to, the following situations:
  1. Transfers from one hospital to another if the above criteria are not met; or
  2. Transfers from a hospital capable of treating an individual to another hospital primarily for the convenience of the individual or the individual's family or healthcare professional; or
  3. When land transportation is available and the time required to transport the individual by land does not endanger the individual's life or health; or
  4. Transportation to a facility that is not an acute care facility, skilled nursing facility or acute rehabilitation facility; or
  5. The services are for the transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead.


REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

The vehicle and crew utilized for air ambulance transport should meet all applicable local, state, and federal regulatory certification and licensing requirements.

BENEFIT APPLICATION

In products without an Out-of-Network benefit (HMO), non-emergency air transport may be covered to transport the member back to an In-Network Facility Provider in the member's service area as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator], when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during air transport, when transport cannot be safely provided by land ambulance. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

In products with an Out-of-Network benefit (PPO and the POS product) non-emergency air transport may be covered to transport the Member back to an In-Network Facility Provider as determined by the (Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during air transport, when transport cannot be safely provided by land ambulance. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.

Description

An air ambulance is a specially equipped aircraft, either an airplane or helicopter, used for medical transportation in situations where either a ground ambulance cannot reach the scene easily or quickly enough, or an individual needs to be transported over a distance or terrain that makes air transportation the most practical transport mode. Air ambulance crews are supplied with equipment that enables them to monitor and provide medical treatment to an individual during transportation.

Emergency air ambulance transportation refers to the transportation of an individual from their home or the scene of an accident or medical emergency, following the sudden onset of an accident or illness, such that delay of immediate medical attention could reasonably be expected to result in serious impairment or loss of life. This may include transportation of an individual from one acute care hospital to another acute care hospital when the original hospital does not have the capacity to effectively treat the individual.

Non-emergency air ambulance transportation refers to the transportation of an individual from an acute hospital inpatient setting to another facility for specialized services. These transports are non-emergent and scheduled in advance.
References


Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10: Ambulance services. Revised 04/03/18. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf. Accessed August 10, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4: Benefits and beneficiary protections. 130.2: Emergency and urgently needed services. (Revised 4/22/16) [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf. Accessed August 10, 2018.

Commonwealth of Pennsylvania. PA Code 28, PART VII. Emergency Medical Services. Chapter 1001. Administration of the EMS System 1001.2: Definitions. [The Pennsylvania Code Web site]. Available at: http://www.nasemso.org/legislation/Pennsylvania/pavii1001.1.html. Accessed August 10, 2018.

Company Benefit Contracts

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41, Subchapter 1, 8:41-1.3: Advanced life support services; mobile intensive care programs, specialty care transport services and air medical services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf Accessed August 10, 2018.

New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41a, Subchapter 1, 8:41a-1.3: Emergency Medical Technicians --- Paramedic: training and certification. [NJ Department of Health and Senior Services Web site]. Available at:
http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841ar.pdf. Accessed August 10, 2018.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



A0140 Nonemergency transportation and air travel (private or commercial) intra- or interstate

A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged);

A0430 Ambulance service, conventional air services, transport, one way (fixed wing)

A0431 Ambulance service, conventional air services, transport, one way (rotary wing)

A0435 Fixed wing air mileage, per statute mile

A0436 Rotary wing air mileage, per statute mile

S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)

S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)



Revenue Code Number(s)

0545 Ambulance - Air Ambulance

Coding and Billing Requirements


Cross References


Policy History

Revisions 12.04.03c
01/01/2019This version of the policy will become effective 01/01/2019.

This policy was updated to revise policy coverage criteria regarding Air Ambulance Services.

The following HCPCS code has been deleted from this policy:

A0999 Unlisted ambulance service

The following revenue code has been deleted from this policy:

0549 Ambulance Other Ambulance


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/02/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.