ModifiedBlue Cross Blue Shield of VermontPolicy 10.01.VT05

Ambulance and Medical Transport Services (Ground, Air and Water) Corporate Medical Policy

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This policy governs coverage and medical-necessity criteria for emergency and non-emergency ground ambulance transportation and exceptional air or water ambulance transportation for ill or injured members. It also addresses ambulance response without transport, paramedic or AEMT intercepts, emergent ECG services, licensing, prior approval, and exclusions.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAmbulance and Medical Transport Services (Ground, Air and Water)

Policy CodePolicy 10.01.VT05

Change TypeModified

Effective DateOct 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior approval for all non-emergent ambulance transportation services before providing transport.

SourceLink

POLICY UPDATE CHANGES

In June 2025, the policy reinstated the prior approval requirement for non-emergent land transport codes A0426 and A0428 because of high utilization of services determined not medically necessary.

In October 2024, the prior approval requirement for non-emergent ground transport codes A0426 and A0428 was removed.

In November 2021, ambulance response and treatment without transport, code A0998, was added as medically necessary with criteria.

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ModifiedBlue Cross Blue Shield of VermontPolicy 10.01.VT05

Ambulance and Medical Transport Services (Ground, Air and Water) Corporate Medical Policy

Customize your policy alerts

Sign up for bcbsvermont Policy 10.01.VT05 alerts

Get alerted when Policy 10.01.VT05 changes without checking for updates manually.

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAmbulance and Medical Transport Services (Ground, Air and Water)

Policy CodePolicy 10.01.VT05

Change TypeModified

Effective DateOct 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior approval for all non-emergent ambulance transportation services before providing transport.

SourceLink

POLICY UPDATE CHANGES

In June 2025, the policy reinstated the prior approval requirement for non-emergent land transport codes A0426 and A0428 because of high utilization of services determined not medically necessary.

In October 2024, the prior approval requirement for non-emergent ground transport codes A0426 and A0428 was removed.

In November 2021, ambulance response and treatment without transport, code A0998, was added as medically necessary with criteria.

3Ambulance service modes addressed

300 milesPost-hospital ground transport distance limit

A0998Covered response-without-transport code

9Codes or code families requiring non-emergent prior approval

21Codes listed as not medically necessary or excluded

Medical Necessity and Coverage Criteria

Emergency ground ambulance

Emergency ground ambulance transportation within the United States may be considered medically necessary when all criteria are met.

Appropriate ambulance resources: The ambulance is equipped with appropriate emergency and medical supplies, equipment, and personnel.
Other transportation contraindicated: The member's clinical condition is such that any other form of transportation would be medically contraindicated.
Nearest appropriate facility: The member is transported to the nearest facility with the appropriate capabilities for treatment of the illness or injury.

Non-emergency ground ambulance

Non-emergency ground ambulance transportation within the United States may be considered medically necessary when the overarching safety criterion and one or more qualifying circumstances are met.

One or more qualifying transport circumstances
- A. Acute-care facility transfer: The transfer is from an acute care facility or clinic to another acute care facility or clinic; the member is registered as an inpatient; specialized services are unavailable at the current facility, are reasonable, medically necessary, and covered under the member's contract; and the receiving facility is the nearest facility with the required capabilities.
- B. Skilled nursing or rehabilitation transfer: The transport is from a skilled nursing or rehabilitation facility to the closest appropriate facility to treat the member's condition.
- C. Approved post-hospital facility transfer: After an approved hospitalization, the transport is from a hospital to a Blue Cross VT-approved skilled nursing, rehabilitation, or hospice facility not more than 300 miles from the discharging hospital.not more than 300 miles
  If the destination is greater than 300 miles from the discharging hospital, the additional criteria in the greater-than-300-mile exception apply.

Greater-than-300-mile exceptions

For the greater-than-300-mile exceptions in sections C and E, all additional criteria must be met.

Greater-than-300-mile exception: The member is registered as an inpatient in an acute care facility; specialized services are unavailable in that facility and are reasonable, medically necessary, and covered under the member's contract; and, for the section C facility transfer, the destination is the nearest facility with the required capabilities.greater than 300 miles

Applies to the specified section C facility transfer and section E transport home exceptions.

Air or water ambulance

Air or water ambulance transportation may be considered medically necessary only when the applicable ground ambulance criteria are met and at least one exceptional circumstance is present.

One or more exceptional air/water circumstances
- Immediate rapid transport: The member's medical condition requires immediate and rapid transport to the nearest appropriate medical facility, and ground ambulance could not have been provided without posing a threat to the member's health.
- Inaccessible pickup point: The point of pickup is inaccessible by ground ambulance.
- Distance, time, or obstacles: Great distances, limited time frames, or other obstacles are involved in getting the member to the nearest hospital with appropriate facilities for treatment.

Death after ambulance dispatch

Ambulance or medical transport services may remain eligible when the member is legally pronounced dead after the ambulance was called and the applicable medical-necessity criteria are met.

Death after ambulance dispatch: The member is legally pronounced dead after the ambulance was called but before pickup, or while en route to an acute-care facility, AND the applicable medical-necessity criteria are met.

Paramedic and AEMT intercepts

Paramedic intercept or AEMT intercept services may be considered medically necessary when consistent with the most current Vermont Statewide Emergency Medical Services Protocols and applicable policy criteria.

Paramedic or AEMT intercept: The intercept is consistent with the most current Vermont Statewide Emergency Medical Services Protocols and meets the applicable medical-necessity criteria in this policy.

Vermont EMS protocols direct providers to call for a paramedic intercept if available and, if unavailable, an AEMT intercept if available, based on the clinical situation and availability.

Emergent ECG/EKG

Emergent acquisition and transmittal of a 12-lead ECG or EKG may be medically necessary when the following criterion is met.

Emergent ECG/EKG: A 12-lead ECG or EKG is acquired and transmitted under emergent circumstances and is indicated by current Vermont Statewide Emergency Medical Services Protocols.12-lead ECG

Ambulance response without transport

Ambulance response and treatment without transport, HCPCS A0998, may be considered medically necessary when all criteria are met.

Response and treatment without transport

9-1-1 response: The services follow a response originating through a 9-1-1 call.
Consent: The member consents to evaluation and treatment.
No medical emergency: After evaluation, the medic and member agree that there is not a medical emergency.
EMS-protocol treatment: Evaluation and treatment are rendered to the member per EMS protocols.

Coverage is not available when the member is legally pronounced dead before the ambulance is called. Eligibility may remain possible when death occurs after the ambulance was called, subject to the applicable medical-necessity criteria.

Transportation to a morgue or funeral home is not medically necessary and is not eligible for benefits.

Ambulance transportation is not eligible when the member's condition is appropriate for private transportation, regardless of whether private transportation is available.

Ambulance transportation is not eligible when it is provided solely for the convenience of the physician, family, or member.

Charges for administrative fees, reusable equipment, and nonreusable or disposable supplies are not medically necessary and are not eligible for benefits.

Transportation provided to obtain a service that is not medically necessary by the Plan is also considered not medically necessary and is not eligible for benefits.

Transport by a non-licensed ambulance service is not medically necessary and is not eligible for benefits.

Ambulance transportation to or from a physician's office for a routine office visit is not medically necessary and is not eligible for benefits.

Transport that is 300 miles or greater from the discharging hospital is not medically necessary when medically necessary treatment is available within 300 miles of that hospital.

Air or water ambulance transportation is not eligible unless it meets the applicable ground ambulance medical-necessity criteria and at least one specific air- or water-transport criterion, such as the need for immediate rapid transport when ground transport would threaten the member's health, an inaccessible pickup point, or significant distance, time, or other obstacles.

The policy identifies several transportation services as contract exclusions, including non-emergency taxi transportation (A0100), private or commercial air travel (A0140), and ancillary transportation expenses such as parking, tolls, lodging, and meals (A0170-A0210). The listed services are not eligible under the applicable contract provisions.

The circumstances identified as not medically necessary are not eligible for benefits. These include transportation appropriate by private means, convenience transportation, routine physician-office transportation, non-licensed ambulance transport, disallowed distance transport, and air or water transport that does not meet the required ground and exceptional air- or water-transport criteria.

The policy identifies listed non-emergency transportation and related services as not medically necessary, non-covered, or contract exclusions. These include volunteer or individually provided mileage (A0080-A0090), out-of-state Medicaid-only mileage (A0021), bus, minibus, wheelchair van, caseworker or social-worker transportation, routine BLS or ALS disposable supplies (A0382, A0398), ambulance waiting time (A0420), an extra attendant (A0424), excess or non-covered mileage (A0888), and non-emergency transportation mileage (S0215).

Covered and Non-Covered Codes

Ambulance response and treatment without transportHCPCSCovered

A0998

Ambulance response and treatment, no transport

Codes considered medically necessary when applicable criteria are metHCPCSCovered

A0225	Ambulance service, neonatal transport, base, rate, emergency transport, one way.
A0380	BLS mileage per mile.
A0384	BLS specialized service disposable supplies; defibrillation.
A0390	ALS mileage per mile.
A0392	ALS specialized service disposable supplies; defibrillation.
A0394	ALS specialized service disposable supplies; IV drug therapy.
A0396	ALS specialized service disposable supplies; IV drug therapy.
A0422	Ambulance (ALS or BLS) oxygen.
A0425	Ground mileage, per statute mile.
A0426	Ambulance service, advanced life support, non-emergency transport.

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Codes denied as not medically necessary, non-covered, or contract exclusionsHCPCSNot Covered

A0080	Non-emergency transportation; per mile volunteer — Not Medically Necessary.
A0090	Non-emergency transport per mile vehicle provided by individual — Not Medically Necessary.
A0021	Ambulance service, outside state per mile, transport Medicaid only — Not Medically Necessary.
A0100	Non-emergency transportation; taxi — Contract Exclusion.
A0110	Non-emergency transportation and bus, intra- or interstate carrier — Not Medically Necessary.
A0120	Non-emergency transportation; mini-bus, mountains area transports, or other transportation systems — Not Medically Necessary.
A0130	Non-emergency transportation; wheelchair van — Not Medically Necessary.
A0140	Non-emergency transportation and air travel (private or commercial) intra- or interstate — Contract Exclusion.
A0160	Non-emergency transportation: per mile-caseworker or social worker — Not Medically Necessary.
A0170	Transportation ancillary: parking fees, tolls, other — Contract Exclusion.

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Post-hospital or home transport distance

Distance limitNot more than 300 miles from the discharging hospital

Applies toApproved post-hospital transport to a skilled nursing, rehabilitation, hospice facility, or the member's permanent home or residence

RestrictionTransport 300 miles or greater is not medically necessary when medically necessary treatment is available within 300 miles

Pediatric quaternary-to-tertiary transfer distance

Patient populationMember under chronological age 5 or the developmental equivalent

Transfer setting

Authorization, Documentation, and Denial Prevention

Prior Authorization

Prior Approval for Non-Emergent Ambulance Transport

Prior approval is required for all non-emergent ambulance transportation services. Benefits remain subject to all terms, limitations, and conditions of the member’s subscriber contract.

Obtain approval before providing non-emergent ambulance transportation.
Incomplete authorization requests may delay the decision while missing information is obtained.

Prior Authorization

Non-Emergent Ground Transport Requires Approval

Obtain prior approval for non-emergent ground ambulance transportation, including both ALS and BLS services. The prior-approval requirement for the non-emergent ground transport codes was reinstated.

A0426 — Ambulance service, advanced life support, non-emergency transport.
A0428 — Ambulance service, basic life support, non-emergency transport.

Policy Scope and Service Context

Ambulance and medical transport services use specially designed and equipped ground, air, or water vehicles to transport ill or injured members in emergency and non-emergency situations. Basic Life Support vehicles provide basic interventions, while Advanced Life Support vehicles provide specialized life-sustaining equipment and trained personnel. Coverage focuses on whether the member's condition makes other transportation unsafe and whether the destination is the nearest appropriate facility.

Transportation Service Definitions

Basic Life Support (BLS)

ProvidesTransportation plus the equipment and staff needed for basic services

Basic servicesControl of bleeding, splinting fractures, treatment of shock, delivery of babies, and cardiopulmonary resuscitation (CPR)

OxygenOxygen charges may be billed separately

Advanced Life Support (ALS)

EquipmentComplex, specialized life-sustaining equipment

Personnel capabilitiesPersonnel trained and authorized to administer IVs, provide ALS medications, establish and maintain a patient's airway, and defibrillate the heart

Separate billing

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAmbulance and Medical Transport Services (Ground, Air and Water)

Policy CodePolicy 10.01.VT05

Change TypeModified

Effective DateOct 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2027

Key ActionObtain prior approval for all non-emergent ambulance transportation services before providing transport.

SourceLink

On This Page

D. Dire-need physician-office stop: The transport is to a physician's office because the ambulance stops there due to dire need for professional attention, and the ambulance immediately thereafter continues to the closest facility that can provide services appropriate for treatment of the condition.

E. Terminally ill transport home: After an approved hospitalization, the transport is to the member's permanent home or residence, the home is not more than 300 miles from the discharging hospital, and the member is terminally ill.not more than 300 miles; life expectancy of six months or less

If the home is greater than 300 miles from the discharging hospital, the additional criteria in the greater-than-300-mile exception apply.

F. Post-hospital transport home: After an approved hospitalization, the transport is to the member's permanent home or residence not more than 300 miles from the discharging hospital.not more than 300 miles

G. Postpartum mother: The member is a postpartum mother transported within the first 72 hours after delivery of a live infant that required emergent transport to a higher level of care.within the first 72 hours after delivery

H. Young child acute-care transfer: The member is under chronological age 5 or the developmental equivalent, is registered as an inpatient in a quaternary facility, and is transferred to a tertiary facility for continued acute or intensive care.under age 5 or developmental equivalent; not more than 400 miles

I. Incidental transport outside the United States: The transport incidentally occurs outside the United States; the member is registered as an inpatient in an acute care facility; specialized services are unavailable there, are reasonable, medically necessary, and covered under the member's contract; and the destination is the nearest facility with the required capabilities.

No emergency-department transport desired: The member does not desire transport to an emergency department for evaluation.

Stable for referral: The member is stable for referral to and follow-up with a primary care provider or other community resource.

Ability to obtain follow-up: The member has the mental capacity and transportation resources to obtain assistance and medically indicated follow-up.

Registered as an inpatient in a quaternary facility and transferred to a tertiary facility for continued acute or intensive care

Maximum distanceNot to exceed 400 miles

Postpartum transport timing

TimingWithin the first 72 hours after delivery

PatientPostpartum mother

Infant-related requirementThe live infant required emergent transport to a higher level of care

Terminal illness prognosis

PrognosisLife expectancy of six months or less

Clinical assumptionThe illness runs its normal course

Determined byA licensed treating provider

Prior Authorization

Non-Emergent Air and Specialty Transport Requires Approval

Obtain prior approval for non-emergent air ambulance and specialty-care transportation, including fixed-wing and rotary-wing services and the associated mileage codes.

A0430 — Conventional air service, fixed-wing transport, one way.
A0431 — Conventional air service, rotary-wing transport, one way.
A0434 — Specialty care transport.
A0435 — Fixed-wing air mileage, per statute mile.
A0436 — Rotary-wing air mileage, per statute mile.
S9960 — Non-emergency fixed-wing air transport, one way.
S9961 — Non-emergency rotary-wing air transport, one way.

Prior Authorization

Unlisted Ambulance Service Requires Approval

Unlisted ambulance services require prior approval before billing.

A0999 — Unlisted ambulance service.

Documentation Required

Maintain Licensing, Permits, Equipment, and Supplies

Comply with all applicable local, state, and federal laws. Maintain appropriate, valid licenses and permits and ensure the ambulance or other medical transport service has the required patient-care equipment and supplies.

Maintain credentials for the level of service provided, including BLS or ALS licensing requirements.
Ensure required staff, equipment, and supplies are available for the service.

Documentation Required

Document Medical Necessity and Destination

Document the member’s clinical condition, why other transportation is medically contraindicated, and why the destination is appropriate. Ground ambulance medical necessity generally requires transport to the nearest facility with the capabilities needed to treat the illness or injury.

For non-emergency ground transport, document that the condition prevents safe transportation by any other means and the applicable qualifying circumstance.
Document inpatient status, unavailable specialized services, contract coverage, facility capability, and nearest appropriate destination when applicable.
For air or water transport, document that ground-transport criteria are met and the additional air/water criterion is satisfied.
An appropriate facility has the necessary expertise, equipment, and ability to accept the member.

Documentation Required

Document No-Transport Responses

For ambulance response and treatment without transport, document the complete response, evaluation, treatment, and disposition record.

Response originated through a 9-1-1 call.
Member consented to evaluation and treatment.
Medic and member agreed after evaluation that there was no medical emergency.
Evaluation and treatment followed EMS protocols.
Member declined emergency-department transport and was stable for referral and follow-up.
Member had the mental capacity and transportation resources to obtain follow-up care.

Documentation Required

Document EMS Protocol Compliance

Document that paramedic or AEMT intercepts and emergent 12-lead ECG acquisition and transmission were consistent with the most current Vermont Statewide Emergency Medical Services Protocols and met applicable medical-necessity criteria.

For intercepts, document the clinical situation, availability, and protocol basis for obtaining the intercept.
For emergent ECG/EKG services, document the emergent circumstances and protocol indication.

Unsupported block type: prior_auth

Denial Risk

Non-Covered Transport Circumstances

The following circumstances are not medically necessary and are not eligible for benefits.

The member was pronounced dead before the ambulance was called.
Transportation is to a morgue or funeral home.
The member’s condition is appropriate for private transportation, regardless of whether private transportation is available.
Transportation is solely for the convenience of the physician, family, or member.
Transportation is for a routine physician-office visit.
The ambulance service is provided by a non-licensed ambulance service.

Denial Risk

Non-Covered Charges and Services

Do not bill non-covered administrative, equipment, supply, or ancillary charges, and do not transport solely to obtain a service that the Plan considers not medically necessary.

Administrative fees, reusable equipment, and nonreusable or disposable supplies are not eligible.
Transportation for a service that is not medically necessary is also not medically necessary.
Confirm coverage for the underlying service before arranging transportation.

Denial Risk

Apply Distance and Air/Water Restrictions

Apply the policy’s distance and air/water restrictions when selecting and billing transportation. Transport 300 miles or greater from the discharging hospital is not medically necessary when medically necessary treatment is available within 300 miles.

Transfers to an approved skilled nursing, rehabilitation, or hospice facility and transports home after hospitalization generally must not exceed 300 miles, subject to the policy’s additional criteria for greater distances.
A child under age 5 transferring from a quaternary to a tertiary facility may not exceed 400 miles when the stated criteria are met.
Air or water transport must meet all applicable ground ambulance medical-necessity criteria plus an additional criterion: immediate and rapid transport where ground would threaten health, an inaccessible pickup point, or great distance, limited time, or another obstacle.

Note

Verify Member-Specific Benefits

Verify the member’s specific benefits before providing service. Contract language and applicable group, Federal Employee Program, or Administrative Services Only plan documents may change or control coverage.

Confirm the member’s contract and group or individual benefit provisions.
Contact the health plan for NEHP/ABNE benefit differences when applicable.
Verify Federal Employee Program benefits through FEP customer service or the Service Benefit Plan Brochure.
For ASO groups, consult the employer benefit plan documents or customer service.
Member contract or applicable employer-plan language takes precedence over medical policy when there is a conflict.

Denial Risk

Excluded or Not Medically Necessary Services

The following transportation, ancillary, supply, waiting-time, attendant, mileage, and miscellaneous services are denied as not medically necessary, non-covered, contract exclusions, or investigational as indicated.

A0080, A0090, A0110, A0120, A0130, A0160, A0382, A0398, A0420, A0424, A0888, and S0215 — Not Medically Necessary.
A0021 — Not Medically Necessary.
A0100, A0140, A0170, A0180, A0190, A0200, and A0210 — Contract Exclusion.
A0424 extra ambulance attendant requires medical review and is listed as Not Medically Necessary.

Denial Risk

Medical Review Required for A0998

Suspend HCPCS A0998 for medical review before processing or payment.

A0998 — Ambulance response and treatment, no transport.
Use medical review to determine whether the response satisfies the policy’s 9-1-1, consent, evaluation, treatment, stability, and follow-up criteria.

Listed services and oxygen may be billed separately by the ambulance provider

Terminally ill

DefinitionThe member's medical prognosis is a life expectancy of six months or less if the illness runs its normal course

Determined byA licensed treating provider

Applicable contextThe definition is used for qualifying transport to the member's permanent home or residence after an approved hospitalization

Appropriate facility

ExpertiseHas the necessary expertise

EquipmentHas the necessary equipment

Acceptance capabilityHas the ability to accept the member