Currentblue cross blue shield - south dakotaPolicy N/A

Air Ambulance

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Defines coverage criteria, prior approval requirements, and coding for emergency and non-emergency air ambulance transport for Wellmark members; applies to providers requesting reimbursement for air medical transport services.

Policy Summary

Payerblue cross blue shield - south dakota

PolicyAir Ambulance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2012

Last ReviewApr 1, 2025

Next Review DateApr 1, 2025

Key ActionObtain prior approval and submit documentation of medical necessity for non-emergency air ambulance transports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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Currentblue cross blue shield - south dakotaPolicy N/A

Air Ambulance

Customize your policy alerts

Sign up for all blue cross blue shield - south dakota policy alerts

Know when blue cross blue shield - south dakota releases new policies or updates existing guidance.

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Policy Summary

Payerblue cross blue shield - south dakota

PolicyAir Ambulance

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2012

Last ReviewApr 1, 2025

Next Review DateApr 1, 2025

Key ActionObtain prior approval and submit documentation of medical necessity for non-emergency air ambulance transports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Coverage Criteria for Air Ambulance Transport

Emergency transport (covered when ALL met)

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

Emergency coverage criteria: The member is experiencing an emergency medical condition requiring immediate ambulance transport.

Supported by emergency medical condition definition in policy

Access/Distance: 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.

Use of air ambulance is generally considered when land transport time or instability poses a threat to survival or seriously endangers health

Destination: The member is transported to the nearest hospital with adequate facilities to treat the member's medical condition.

Transporting much farther than the nearest adequate hospital typically suggests the condition was not emergent

Inpatient availability: 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.

Air-only services required: During transport, the member's medical condition requires services that are provided only by an air ambulance.

Non-emergency transport (covered when ALL met + prior approval)

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

Current care setting: The member is already receiving care at a hospital.

Destination: The member is transported to the nearest hospital or nursing facility with adequate facilities to treat the member's condition (or to a facility previously approved by Wellmark).

If Wellmark approved destination, requirement considered met

Service availability: 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.

Transport safety: Documentation in the medical record indicates that the member cannot be reasonably and safely transported by other modes of transportation.

Air ambulance transport that does not meet the policy's stated medical necessity criteria is not medically necessary. Examples include transport from or to a facility that is already capable of treating the member's condition, situations where the member is physically and mentally capable of being a passenger in a private vehicle, and transports performed primarily for convenience of the member, family, or provider.

Also considered not medically necessary are round-trip transports for routine appointments, non-ambulance modes of transport (for example, private vehicles, commercial air, police transport, rideshare services, public transportation, or vehicles not professionally operated or staffed for medical transport), and repatriation from an international location except when returning to the nearest hospital adequately equipped to treat the condition.

Any air ambulance transport that fails to meet the emergency or non-emergency medical necessity criteria outlined elsewhere in this policy will be denied as not medically necessary. Denial reasons include lack of documentation supporting medical necessity, availability of appropriate care at the originating facility, or when alternative, non-air modes of transport are reasonable and safe.

Providers should ensure documentation clearly supports why air transport was required (for example, inability to be safely transported by other means or need for services available only via air) because transports primarily for convenience, routine appointment trips, or use of non-ambulance conveyances are not eligible for coverage.

Coding — HCPCS / CPT and Revenue Codes

Air ambulance HCPCS/CPT 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.
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing).
S9961	Ambulance service, conventional air services, nonemergency transport, one way (rotary wing).

Revenue CodesRevenue

0545	Revenue code - Air Ambulance

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required

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

Note

Hierarchy of Transport Modes — Ground Preferred

When determining mode of transport, ground ambulance is the preferred mode unless clinical circumstances justify air transport. Air ambulance (rotary or fixed wing) should be used only when one or more of the following apply: the member is experiencing an emergency medical condition requiring immediate transport; great distances or geographic inaccessibility prevent timely ground transport; the member requires services during transport that are available only on an air ambulance; or the member cannot be safely or reasonably transported by ground or other modes.

Prefer ground transport unless clinical criteria justify air transport
Air ambulance appropriate when distance, inaccessibility, or need for air-only services exists
Use nearest facility with adequate capabilities

Definitions

Air Ambulance definition

TermAir Ambulance

DefinitionLicensed and certified aircraft (airplanes or helicopters) specially designed and equipped to provide rapid emergency medical care and transport of ill or injured patients.

Equipment/CapabilitySpecially designed and equipped to support emergency medical care during flight (fixed- or rotary-wing).

Emergency medical condition definition

TermEmergency medical condition

DefinitionA medical condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate medical attention to result in: placing the individual's (or pregnant woman's and unborn child's) health in serious jeopardy; serious impairment of bodily function; or serious dysfunction of any bodily organ or part.

Background

Air ambulance services provide rapid emergency medical care and patient transport using specially designed and equipped fixed- or rotary-wing aircraft that are licensed and certified as air ambulances. They are intended for situations when ground transport is too slow, inaccessible, or cannot provide the required skilled monitoring during transport.

Use of air ambulance is appropriate when it is necessary to move a patient quickly to the nearest hospital with adequate facilities, when great distances or obstacles make ground transport impractical, or when the patient's condition requires monitoring or interventions that can only be delivered in an air ambulance.

Revision History

2012-04-01Effective

Policy originally effective as of April 1, 2012.

2017-12-01Revision

Interim review and policy revision completed in December 2017.

2024-03-01Review/Revision

Annual review and policy revised in March 2024.