Commercial

Air Ambulance Services
12.04.03c

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.

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.

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. [CMS Web site]. (Revision # 243: 04/03/18). Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf. Accessed April 19, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4: Benefits and beneficiary protections. §130.2: Emergency and urgently needed services. [CMS Web site]. (Revision #121: 4/22/16). Available at: http://www.cms.hhs.gov/manuals/downloads/mc86c04.pdf. Accessed April 19, 2019.

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: https://www.pacode.com/secure/data/028/chapter1051/s1051.2.html. Accessed April 19.2019.

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 April 19, 2019.

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 April 19, 2019.

Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

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


Policy History

1/1/2019
1/2/2019
6/30/2021
12.04.03
Medical Policy Bulletin
Commercial
No