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Blue Cross Blue Shield of Mississippi (BCBSMS) does not pay for medically unnecessary services, so any transport that is not medically necessary will be denied in its entirety.  A prudent layperson standard will be applied to emergency EMS calls with more rigorous medical standards applied to other calls.

A given transport may be emergency or non-emergency. An emergency response is one that, at the time the ambulance provider is called, it responds immediately.  An emergency is a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical condition could reasonably be expected to result in placing the patient's health in serious jeopardy; impairment to bodily functions; or serious dysfunction to any bodily organ or part. A non-emergency response is covered when it meets all medical necessity requirements as stated in the policy section.  Non-emergency response services can be scheduled or unscheduled.  Also some non-emergency transport is based on the status of the patient being "bed confined."  For bed confinement, all of the following criteria must be met:

• the patient is unable to get up from bed without assistance; and
• the patient is unable to ambulate; and
• the patient is unable to sit in a chair or wheelchair

Ambulance services can be delivered at four levels:

Basic Life Support (BLS): Ground transportation and the provision of medically necessary supplies and services, including BLS ambulance services as defined by the State.  The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as an emergency medical technician - basic (EMT-Basic).  BLS provides techniques and skills included in an EMT basic training course to individuals as they are transported to the nearest hospital.    

Basic Life Support (BLS) - Emergency: When medically necessary, the provision of BLS services, as specified above, in the context of an emergency response (defined below).  An emergency response is one that, at the time the ambulance provider is called, it responds immediately.  An immediate response is one in which the ambulance provider begins as quickly as possible to take the steps necessary to respond to the call. An emergency is a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical condition could reasonably be expected to result in placing the patient's health in serious jeopardy; impairment to bodily functions; or serious dysfunction to any bodily organ or part.

Advanced Life Support, Level 1 (ALS1):  When medically necessary, the provision of an assessment by an ALS provider or the provision of one or more ALS intervention. An ALS provider is defined as a provider trained at the level of EMT- Intermediate or Paramedic as defined in the National EMS Education and Practice Blueprint.  An ALS intervention is defined as a procedure that is in accordance with State and local laws, required to be performed by an EMT-Intermediate or EMT-Paramedic.

Advanced Life Support, Level 1 (ALS1) - Emergency: When medically necessary, the provision of ALS1 services, as specified above, in context of an emergency response. An emergency is a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical condition could reasonably be expected to result in placing the patient's health in serious jeopardy; impairment to bodily functions; or serious dysfunction to any bodily organ or part.

Advanced Life Support, Level 2 (ALS2):  When medically necessary, the administration of three or more different medications and the provision of at least one of the following procedures:

• Manual defibrillation/cardioversion;
• Endotracheal intubation;
• Central venous line;
• Cardiac pacing;
• Chest compression;
• Surgical airway; or
• Intraosseous line

Specialty Care Transport (SCT): When medically necessary, interfacility transportation of a critically injured or ill patient by ground ambulance, at a level of service beyond the scope of the EMT-Paramedic.  This is necessary when a patient's condition requires ongoing care that must be provided by one or more health professionals in an appropriate specialty area, e.g., nursing, medicine, respiratory care, cardiovascular care or a paramedic with additional training. 

Coverage extends only to the transportation of the individuals who cannot be transported by other means, whether or not those other means are available.  Typically this is limited to either bed-confined individuals or to patients requiring constant medical attendance during transport.  The vehicle must be a true ambulance with appropriate equipment for its level of service, and mileage is only covered to the nearest facility capable of providing the needed services.  Transport to and from a physician's office is not covered.

I.  Ground Ambulance Services

Emergency Transport

Ground emergency medical transport services are considered medically necessary when all of 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
• 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 an organ transplantation, to the approved transplant facility.

Ambulance providers are required to respond to all emergency calls, but occasionally after assessment transport is declined by the patient.  In such cases, the appropriate base rate HCPCS code without mileage may be considered for payment. 

Non-Emergency Transport

Ground non-emergency medical transport services between health care facilities are medically necessary when all of 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
• Prior authorization has been received for transport; and
• Transportation to or from one hospital or medical facility to another hospital or medical facility, in order to obtain medically necessary diagnostic or therapeutic services (e.g., MRI, CT scan, acute interventional cardiology, intensive care unit services, etc.) which are unavailable at the originating facility; and
• The provider of the specialized service is the nearest one with the required capabilities.

Ground non-emergency medical transport of bed-confined individuals to a lower level of care may be considered medically necessary when the all of the following criteria are met: 

• The patient’s condition is such that the use of any other method of transportation is contraindicated; AND
• The patient meets all of the following bed-confinement criteria:
  • Unable to get up from bed without assistance; and
  • Unable to ambulate; and
  • Unable to sit in a chair or wheelchair, AND
• The ambulance trip report provides a detailed description of the patient’s symptoms and physical findings at the time of transport, including functional status, safety issues, and special precautions or monitoring performed.

Ground ambulance services for deceased patients may be considered medically necessary when the criteria above have been met and when either of the following is present:

1. The patient was pronounced dead while in route or upon arrival at the hospital or final destination; or
2. The patient was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick up.  The provider should bill the appropriate base rate HCPCS code without mileage.

II.  Air Ambulance Services

All air ambulance services require authorization.

In exceptional circumstances, air ambulance services from the site of accident, injury or illness may be medically necessary. In these circumstances, all of the criteria pertaining to ground transportation must be met as well as the following:

• The ambulance must have the necessary patient care equipment and supplies to address the needs of the patient;
• The patient's medical condition requires immediate and rapid ambulance transport that could not be provided by land ambulance;
• The point of pick up may be inaccessible by land vehicle;
• Great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment, e.g., transport of a critically ill patient to an approved transplant facility with awaiting organ;
• The patient's condition is such that the time needed to transport a patient by land poses a threat to the patient's health.

The use of air ambulance services to transport a patient from one hospital to another requires that:

• The above criteria must be met, and
• The first hospital does not have the required services and facilities to treat the patient.

III. Medically Unnecessary Ambulance Services

Use of ambulance services (ground or air) is considered not medically necessary when:

1. The criteria specified for ground and air ambulance services have not been met; or 
2. The services are primarily for the convenience of the patient, patient's family or physician; or
3. The services are for a transfer to a lower level of care, nursing facility, physician’s offices, or patient's home, unless the patient meets the bed-confinement criteria listed above; or 
4. Transportation from a facility to one for a specialized service with expectancy of returning to the original facility; or
5. Transportation for routine renal dialysis; or
6. The services are for a transfer of a deceased patient to a funeral home, morgue, or hospital, when the individual was pronounced dead before the ambulance is called.
7. Transportation by regularly scheduled commercial craft (boat, bus, train or plane) is not medically necessary and therefore not covered.

If a life-support ambulance is used, the equipment must also be used for it to be covered.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member' specific benefit plan language.

1/17/2001: HCPCS A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436 added covered codes

4/18/2002: Type of Service and Place of Service deleted

8/2002: Policy reviewed by MPAC; clarification of commercial craft and Continental coverage

12/11/2002: HCPCS Q3019 added

12/22/2003: Code Reference section updated, HCPCS A0030, A0040, A0050 deleted, HCPCS A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0422, A0424, A0999, S0215 added covered codes, HCPCS A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0160, A0170, A0180, A0190, A0200, A0210, A0420, A0888, Q3020, T2001, T2002, T2003, T2004, T2005, T2006, T2007 added non-covered codes, HCPCS A0140 description revised and code moved to non-covered, HCPCS A0432 moved to non-covered codes

3/17/2004: HCPCS A0800 added

9/10/2004: Code Reference section updated, "Note: Included in the global ambulance service" added to HCPCS A0382, A0384, A0392, A0394, A0396, A0398, HCPCS Q3020 moved to covered

3/07/2006: Coding updated. HCPCS 2006 revisions added to policy

12/27/2006: Code Reference section updated per the 2007 HCPCS revisions

1/7/2009: Policy reviewed, policy section clarified

02/01/2010:  Policy Description revised and added definitions of ambulance transports. Policy Statement revised to include prior approval for non-emergency ground transports and non-emergency air transports; effective February 1, 2010. Also clarified indications for coverage. Exceptions added because prior authorization of non-emergency ground and non-emergency air transports do not apply to FEP & SHP members. Sources Section was updated to add Centers for Medicare and Medicaid Services, Blue Cross Blue Shield of Florida and Empire Blue Cross Blue Shield. Coding Section was revised to remove deleted codes from the Covered Codes Table.  Removed A0800 (deleted 1/1/2007), Q3019 (deleted 4/1/2006) and Q3020 (deleted 4/1/2006).  Added the following verbiage to the Covered Codes Table: "*Some covered procedure codes have multiple descriptions.  Coverage will only be made for covered codes when used for services outlined within the policy statement section." Added the following verbiage to the Non-Covered Codes Table: "*This is not an all inclusive list of non-covered procedure codes."

08/31/2011:  The policy statement regarding air ambulance was revised to remove the word "prior" as follows:  "All air ambulance services require prior authorization" was changed to "All air ambulance services require authorization."

02/01/2012:  Policy statement revised to indicate that ground non-emergency medical transport of bed-confined individuals to a lower level of care may be considered medically necessary when the all of the following criteria are met: The patient’s condition is such that the use of any other method of transportation is contraindicated, AND the patient meets the definition of bed-confined, AND the ambulance trip report provides a detailed description of the patient’s symptoms and physical findings at the time of transport, including functional status, safety issues, and special precautions or monitoring performed.  Other policy statements re-arranged for clarity purposes; intent unchanged.

Blue Cross Blue Shield Association policy # 10.01.05

Blue Cross Blue Shield of Florida Policy

Centers for Medicare and Medicaid Services

Empire Blue Cross Blue Shield Policy

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document.

Covered Codes

This is not an all-inclusive list of non-covered procedure codes. 

The code(s) listed below and ANY code not listed in the previous section are considered non-covered for this procedure.

Non-Covered Codes