CurrentBaylor Scott & White Health PlanPolicy 282

Air Ambulance

Defines medical necessity, prior authorization, documentation, and coding guidance for emergent and non-emergent air ambulance (fixed and rotary wing) transport for Baylor Scott & White Health Plan members in North Carolina. Applies to scene transports and interfacility transfers when criteria are met.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAir Ambulance

Policy CodePolicy 282

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateJan 22, 2027

Key ActionObtain prior authorization for non-emergent interfacility air ambulance transport and provide required documentation including medical history, diagnoses, date of service, origin and destination, one-way mileage, and requesting provider.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Prior authorizationauthorization requirement

8 groupscondition examples

7 itemsdocumentation items

282policy identifier

02/01/2026effective

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Coverage and Medical Necessity Criteria

Emergent air ambulance criteria

BSWHP may consider emergent air ambulance transport medically necessary from the scene OR for interfacility transfers when ALL the following criteria are met:

Emergent transport general criteria: 1) Member transported by scene EMS to the nearest acute care facility capable of treating the member's condition; or for interfacility transfer, the referring facility lacks required services/resources (e.g., burn, cardiac, critical care, obstetrics, pediatric specialty care, stroke, trauma); 2) A delay in transport/transport time poses a threat to survival or seriously endangers life or health — guideline: when ground ambulance transport would take ~30–60 minutes or more for a patient requiring immediate rapid transport; 3) The member's condition is such that any other form of transportation would be medically contraindicated (care and interventions required during transport cannot be provided by standard automotive transport, basic ground ambulance, or ALS ground ambulance); 4) Great distances or other obstacles (road conditions, adverse weather, pickup inaccessible by ground vehicle, etc.) impede ground transport; note: air transport should not bypass an available appropriate facility unless documentation explains the rationale for bypassing the nearest appropriate facility.all four criteria required

See condition-dependent examples for illustrative indications.

Illustrative clinical indications

Examples of conditions that meet the emergent criteria (not all-inclusive):

Cardiac indications: Acute coronary syndromes/AMI with time-critical need for emergent interventional therapy unavailable at the referring facility (e.g., catheterization, emergent cardiac surgery, intraaortic balloon pump); cardiogenic shock; cardiac tamponade; mechanical/anatomic cardiac disease requiring emergent intervention (e.g., acute cardiac rupture, decompensating valvular disease).any

Illustrative examples; not all-inclusive.

Critical illness (medical or surgical): Pre-transport cardiac or respiratory arrest; continuous IV vasoactive medications or mechanical ventricular assist to maintain cardiac output; risk for airway deterioration (e.g., angioedema, epiglottitis); acute pulmonary failure requiring noninvasive positive pressure ventilation or mechanical ventilation during transport; severe poisoning/overdose requiring specialized toxicology; emergent need for hyperbaric oxygen; requirement for emergent dialysis; active GI hemorrhage with hemodynamic compromise; surgical emergencies (e.g., necrotizing fasciitis, aortic dissection/aneurysm, extremity ischemia); septic shock requiring source control.any

Illustrative examples; not all-inclusive.

Neonatal: Gestational age <28 weeks or birth weight <1,500 g or other complicated neonatal course; requirement for supplemental oxygen >60%, CPAP, or mechanical ventilation; seriously ill infants with seizure activity, congestive heart failure, or DIC; neonatal surgical emergencies.

Non-emergent interfacility transport

BSWHP may consider non-emergent interfacility air ambulance medically necessary with prior authorization when ALL the following criteria are met:

Non-emergent interfacility criteria: 1) Member's medical condition prevents safe transportation by any other means as evidenced by ONE of: a) condition requires faster transport than ground/water (e.g., ground transport unavailable >24 hours or ground travel duration excessive), b) requires a critical level of care during transport that cannot be provided by ground/water ambulance, or c) pickup is inaccessible by land/sea; 2) Transportation is for medically necessary care not available at the referring facility; 3) Receiving facility is the nearest appropriate/contracted facility with required capabilities; 4) Member is bed-confined before, during, and after transport, demonstrated by ALL of: a) unable to get up from bed without assistance, b) unable to ambulate, and c) unable to sit in a chair (including a wheelchair); 5) Request submitted by a physician, nursing facility, health-care provider, or other responsible party.all five criteria required

Prior authorization required for non-emergent transports.

Examples of transfers that do not meet the policy criteria include transfers from one hospital to another when the emergent or non-emergent air transport criteria are not satisfied. Transfers arranged primarily for patient, family, or provider preference, transfers to a facility other than the nearest appropriate acute care hospital, and transports to non-acute care locations are cited as situations where air transport would not meet coverage criteria. The policy also identifies transfers that occur when land transport is available and not life- or health-endangering as not meeting criteria for air ambulance coverage.

The provided document chunks do not present an exhaustive exclusions list within the excerpted content; instead, the policy references external clinical and regulatory guidance (professional society papers, Medicare manuals, and state regulations) that inform exclusions and operational considerations.

Ambulance transport is considered not medically necessary when the documented circumstances do not meet the policy's emergent or non-emergent air transport criteria. The policy highlights common examples such as inter-hospital transfers that fail to meet the listed criteria, transports performed for convenience or preference, and movements to non-acute destinations as situations that would be denied as not medically necessary.

Within the provided chunks there are no explicit additional statements labelled 'not medically necessary' beyond the summarized examples; the document instead points readers to referenced clinical and regulatory sources for fuller guidance on utilization and exclusion decisions.

Coding and Transport Time Guidance

HCPCS CodesHCPCS

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
A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
S9960	Ambulance service, conventional air services, non-emergency transport, one-way, fixed wing
S9961	Ambulance service, conventional air services, non-emergency transport, one-way, rotary wing
T2007	Transportation waiting time, air ambulance and nonemergency vehicle, 1/2 hour increments
A0394	ALS specialized service disposable supplies; IV drug therapy
A0396	ALS specialized service disposable supplies; esophageal intubation

1–10 of 18

1/2

ICD-10 CodesICD-10

No codes listed

Codes referencedmixed

No codes listed

Ground transport time guideline — operational threshold when ground transport would take 30-60 minutes or more

Operational thresholdUse air transport when a ground ambulance would take approximately 30–60 minutes or more to reach definitive care for a patient requiring immediate, rapid transport.

ContextApplies when delay in transport poses a threat to survival or seriously endangers life or health.

Related conditionsUsed for scene transports or interfacility transfers when the member's illness/injury requires immediate rapid transport due to severity.

LimitationsAir transport should not bypass an available appropriate facility; if bypass occurs, payment is based on distance to the nearest appropriate facility unless rationale is documented.

Provider Requirements, Authorization & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for non-emergent air ambulance transport. Review the member’s Evidence of Coverage (EOC) or Summary Plan Description (SPD) for plan-specific details and applicability. For Medicare and Medicaid lines of business, follow applicable Medicare NCD/LCD guidance or the Texas Medicaid Provider Procedures Manual (TMPPM) when available; otherwise, apply this policy's criteria.

Applies to all lines of business unless otherwise indicated in member documents.
Medicare: follow NCD/LCD or Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services.
Medicaid: confirm coverage per TMPPM; if no TMPPM criteria, use this policy.

Note

Provider Action: Not Specified

Provider actions: This section does not specify additional procedural steps for the provider beyond submitting requests for authorization and required documentation. No specific extra actions (e.g., step therapy, appeals procedures) are specified in this document section.

Background and Rationale

Air ambulance (helicopter or fixed-wing) provides advanced assessment and critical care capabilities beyond standard paramedic-staffed ground ambulances. It is most beneficial when it shortens time to definitive care for time-sensitive, life‑threatening conditions or when geographic or logistical barriers make ground transport impractical. Professional society and clinical references are cited to support appropriate utilization, emphasizing matching transport modality to patient acuity and the need for rapid access to higher-level care.

Key Definitions

Emergency medical condition — definition (prudent layperson standard)

DefinitionAn emergency medical condition manifests with acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate medical attention to result in serious jeopardy to health, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

Includes maternal considerationsFor a pregnant woman, applies when absence of immediate attention could place her or her unborn child in serious jeopardy.

Standard referencedPrudent layperson standard (average knowledge of health and medicine).

Bed-confined — definition and examples

DefinitionBed-confined: a member who is unable to stand, ambulate, and sit in a chair or wheelchair.

Example: contractures

Policy Version and Review Dates

2026-02-01effective_dateLatest

Policy 282 effective date established.

2026-01-22last_review

Policy 282 last reviewed with minor formatting and grammar changes noted.

2025-08-11update

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyAir Ambulance

Policy CodePolicy 282

Change TypeNo material changes

Effective DateFeb 1, 2026

Next Review DateJan 22, 2027

SourceLink

On This Page

Illustrative examples; not all-inclusive.

Neurologic: Central nervous system hemorrhage requiring emergent intervention; spinal cord compression by mass lesion requiring emergent intervention; evolving ischemic stroke with time-critical need for lytic therapy or acute vascular intervention unavailable at referring facility; status epilepticus.any

Illustrative examples; not all-inclusive.

Obstetric / Pediatric / Transplant / Trauma: Active labor with reasonable expectation that delivery will require obstetric or neonatal care beyond referring hospital capabilities; active premature labor <34 weeks or estimated fetal weight <2,000 g; severe pre-eclampsia/eclampsia; active third-trimester hemorrhage; fetal hydrops; maternal conditions threatening premature delivery; pediatric time-sensitive conditions when referring facility cannot provide required evaluation/therapy; urgent transplant events where timing is critical to organ viability; life- or limb-threatening trauma or burns requiring burn center care.any

Illustrative examples; not all-inclusive.

Request must be submitted by a physician, nursing facility, healthcare provider, or other responsible party.
If air transport is emergent and meets emergent criteria, document accordingly.

Note

Referenced Clinical & Regulatory Guidance

Clinical and regulatory guidance referenced by this policy should be used to inform medical necessity determinations. The document references professional society guidance and regulatory manuals that providers may consult when justifying air transport.

References include Tintinalli's Emergency Medicine, ACEP/AMPA/NAEMSP PREP documents, NAEMSP position statements, and Medicare Benefit Policy Manual Chapter 10.
Providers should consult referenced guidance when clinical judgment is needed to support transport modality.

Documentation Required

Required Documentation

Documentation Required: Submit the minimum documentation elements with all air transport requests to support medical necessity determinations.

Medical history and diagnoses
Date of service
Provider documentation and requesting provider
Point of origin and destination
One-way mileage for transport

Step Therapy

Step Therapy / Additional Provider Requirements

No step therapy or additional utilization management steps are specified in this section. There are also no other provider-specific requirements or actions outlined beyond authorization and documentation.

No step therapy requirements specified.
No additional provider procedural steps specified in this section.

Contractures of lower extremities or fetal position preventing ambulation or ability to straighten the body.

Example: severe weakness/frailtySevere generalized weakness and frailty near end stages of life from a terminal illness preventing ambulation.

Example: neurologic/orthopedic immobilityLower extremity paralysis or immobility (e.g., spica cast, fixed hip joints) making wheelchair transfer impossible.

Example: safety/behavioralMembers with dementia or psychiatric illness where ambulance transport is necessary for safety.

Specialty Care Transport (SCT) — definition (A0434) and when used

DefinitionSpecialty Care Transport (SCT) (procedure code A0434) is interfacility ground transport of a critically ill or injured patient that provides a level of care beyond EMT/paramedic scope and includes medically necessary supplies and services.

When usedWhen a patient's condition requires ongoing care furnished by one or more specialty health professionals (e.g., emergency/critical care nursing, respiratory care, cardiovascular care), or a paramedic with additional training.

ModalityGround ambulance interfacility transport at an advanced specialty level of care (code A0434).

Air Medical Transport / Air Ambulance — definition (helicopter/fixed‑wing)

DefinitionAir Medical Transport / Air Ambulance: transport of patients via helicopter (rotary wing) or fixed‑wing aircraft for emergency response or interfacility transfers when advanced care or speed is required.

PurposeProvides advanced assessment and care beyond paramedic‑staffed ground ambulances and is most beneficial when it shortens time to definitive care for time‑sensitive, life‑threatening conditions.

When indicatedUsed when ground transport would be too slow or inaccessible, or when the member's condition requires capabilities only available via air transport (see emergent and non‑emergent criteria).

Policy language updated to remove 'Medicare NCD or LCD specific InterQual criteria may be used when available.'

2025-01-13review

Reviewed; minor formatting changes and ending note section updated to align with business entity changes.

2024-06-10review

Reviewed with no changes noted.

2024-03-11review

Reviewed; corrected Medicaid section guidance and added Medicare Benefit Policy Manual hyperlink for Medicare plans.

2023-11-29update

Updated to clarify Medicare and Medicaid guidance and add examples for emergency air ambulance use; formatting and hyperlink updates.

2022-02-25review

Reviewed with no changes.

2021-02-25creation

Policy 282 created as a new medical coverage policy.