CurrentBlue Cross Blue Shield - IowaPolicy 10.01.17

Air Ambulance

Defines coverage, prior approval requirements, medical necessity criteria, exclusions, and coding for emergency and non-emergency air ambulance services for Wellmark Blue Cross Blue Shield - Iowa members.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyAir Ambulance

Policy CodePolicy 10.01.17

Change TypeAnnual Review / Revised

Effective DateApr 1, 2012

Next Review Date

Key ActionPrior approval/precertification is required for non-emergency air ambulance services and for services/procedures requiring an inpatient hospital admission.

POLICY UPDATE CHANGES

Policy revised March 2026 at Annual Review.

2Coverage Categories (Emergency, Non-emergency)

6Not-covered scenarios listed

6Key emergency criteria

Coverage Summary

This policy addresses Air Ambulance services — licensed and certified airplane or helicopter medical transports that provide rapid emergency medical care and transport of ill or injured patients. It applies to Wellmark Blue Cross Blue Shield - Iowa members and defines coverage, prior approval requirements, medical necessity criteria, exclusions, and coding for emergency and non-emergency air ambulance services.

Medical-Necessity Criteria

Emergency air ambulance transport - Medically Necessary Criteria

Emergency air ambulance transportation must meet ALL of the following criteria to be covered:

ALL of the following

The member is experiencing an emergency medical condition requiring immediate ambulance transport.
Great distances, inaccessibility of the pickup location by a land vehicle, or other obstacles are involved in getting the member to the nearest hospital with appropriate facilities for treatment by ground ambulance transport.
The member is transported to the nearest hospital with adequate facilities to treat the member's medical condition.
If the member is inpatient, the services required to treat the member's illness or injury are not available where the member is currently receiving care.
During transport, the member's medical condition requires the services that are provided only by an air ambulance.

Non-emergency air ambulance transport - Medically Necessary Criteria

Non-emergency air ambulance transportation may be considered medically necessary when ALL of the following criteria are met:

ALL of the following

The member must already be receiving care at a hospital.
The member is transported to the nearest hospital or nursing facility with adequate facilities to treat the member's condition.
There is documentation in the medical record that the nearest hospital that is equipped to adequately treat the condition has accepted the patient for admission prior to transport.
Precertification is required for services or procedures requiring an inpatient hospital admission.
The services required to adequately treat the member's illness or injury are not available at the hospital where the member is currently receiving care.

Prior Approval

Prior approval requirement for non-emergency services:

ALL of the following

Prior approval is required for non-emergency air ambulance services.

Not Medically Necessary / Exclusions

Not Medically Necessary (Exclusions)

Air ambulance transport is not medically necessary under any of the following circumstances:

ANY of the following

Not meeting the medical necessity criteria above for emergency or non-emergency air transport.
Air or ground ambulance transport from a facility capable of treating the member's condition.
Air or ground ambulance transport to or from any location when the member is physically and mentally capable of being a passenger in a private vehicle.
Air ambulance is used when land transportation is available and the time required to transport by land does not endanger the life or health of the member.
Round-trip transports from the member's residence to a medical provider for an appointment or treatment and back to the member's residence.
Air or ground transport when performed primarily for the convenience of the member or the member's family, physician, or other health care provider, such as a transfer to a hospital or facility that is closer to the member's home or family.
Non-ambulance transport to any location for any reason, including private vehicle, commercial air transport, police transport, taxi, public transportation (train or bus), rideshare (Uber/Lyft), and vehicles equipped to transport stretchers or wheelchairs but not professionally operated or staffed.
Repatriation from an international location other than nearest hospital equipped to adequately treat the member's condition when the above medical necessity criteria are met.

Coding

HCPCS Air Ambulance Transport CodesHCPCSCovered

A0430	Ambulance service, conventional air services, transport, one way (fixed wing)
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)
S9961	Ambulance service, conventional air services, nonemergency transport, one way (rotary wing)
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile

Revenue CodeRevenue

0545	Air Ambulance

Place/Type of Service (Informational)mixed

Inpatient	Place of Service
Home	Place of Service
Physicians Office	Place of Service

Provider Actions & Requirements

Prior Authorization

Precertification for Non-Emergency Air Ambulance

Prior approval/precertification is required for non-emergency air ambulance services and for services/procedures requiring an inpatient hospital admission.

S9960
S9961
A0430
A0431

Documentation Required

Medical Record Documentation Required

For non-emergency transports, documentation must show the member is already receiving care at a hospital, the nearest capable facility has accepted the patient for admission prior to transport, alternative transport is unsafe or unreasonable, and that skilled air-ambulance-level monitoring/care is required during transport.

Member already receiving care at a hospital
Nearest hospital/nursing facility has accepted the patient for admission prior to transport
Documentation that alternative transport modes are unsafe or unreasonable
Need for skilled and medical monitoring provided only by an air ambulance during transport

Denial Risk

Denial Conditions for Non-Covered Scenarios

Claims may be denied if transport does not meet medical necessity criteria, if transport is for convenience, if land transport is available and safe, for round-trip residence appointments, or for non-ambulance transport modes.

Transport primarily for convenience of member/family/provider
Safe and reasonable land transport is available
Round-trip transports from residence to appointments and back
Use of non-ambulance modes (private vehicle, commercial air, taxi, rideshare, police, nonprofessionally staffed stretcher/wheelchair vehicles)

Background & Definitions

Air ambulance services utilize specially designed and equipped airplanes or helicopters and are intended to provide rapid emergency medical care and transport when medically necessary. The policy distinguishes between emergency and non-emergency transports: emergency transports are intended for members experiencing an emergency medical condition and must meet all specified criteria (e.g., need for immediate transport, barriers to ground transport, transport to the nearest appropriate facility, and requirement for services available only via air ambulance).

Non-emergency air ambulance transports may be considered medically necessary only when ALL listed conditions are documented, including that the member is already receiving care at a hospital, the nearest capable facility has accepted the patient for admission before transport, services needed are not available at the current hospital, documentation that other transport modes are unsafe or unreasonable, and that precertification/prior approval has been obtained for non-emergent services or for services requiring inpatient admission.

Definitions

Key operational highlights

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyAir Ambulance

Policy CodePolicy 10.01.17

Change TypeAnnual Review / Revised

Effective DateApr 1, 2012

Next Review Date

Key ActionPrior approval/precertification is required for non-emergency air ambulance services and for services/procedures requiring an inpatient hospital admission.

On This Page

OpenPayer

Air Ambulance

Coverage Summary

Medical-Necessity Criteria

Not Medically Necessary / Exclusions

Coding

Provider Actions & Requirements

Background & Definitions

Revision History