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Ambulance and medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients. These services may involve ground or air transport in both emergency and non-emergency situations.
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:
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:
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.
NOTE: The following only applies to travel within the Continental United States. Travel outside of the Continental United States or to or from the Continental United States is not covered.
I. Ground Ambulance Services
Ground emergency medical transport services are considered medically necessary when all of the following criteria are met:
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.
Ground non-emergency medical transport services between health care facilities are medically necessary when all of the following criteria are met:
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:
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:
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 use of air ambulance services to transport a patient from one hospital to another requires that:
Use of ambulance services (ground or air) is considered not medically necessary when:
POLICY EXCEPTIONSPrior authorization for non-emergency ground transport and non-emergency air transport does not apply to Federal Employee Program and State Health Plan members.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member' specific benefit plan language.
All devices are considered an integral part of the ambulance and medical transport services and no additional benefits are provided for reusable or disposable devices or supplies.
If a life-support ambulance is used, the equipment must also be used for it to be covered.
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
POLICY HISTORY2/1998: Approved by Medical Policy Advisory Committee (MPAC), HCPCS A0030, A0040, A0050, A0140, A0225 added covered codes
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.
07/06/2015: Code Reference section updated for ICD-10.
06/09/2016: Policy number added. Policy Guidelines updated to add medically necessary and investigative definitions.
SOURCE(S)The data compiled for this policy were a combination of local Plan policies and claims experience.
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
CODE REFERENCEThis is may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
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.