CurrentCignaPolicy 0555

Licensed Ambulance Transportation Services (Ground, Air, Water) Coverage Policy

Governs coverage and medical necessity criteria for licensed ground, air (fixed/rotary wing) and water ambulance transport services for Cigna-administered health benefit plans; affects providers requesting reimbursement and utilization reviewers.

Policy Summary

PayerCigna

PolicyLicensed ambulance transportation services — coverage and medical necessity criteria

Policy CodePolicy 0555

Change TypeAnnual review — no clinical statement changes

Effective DateAug 15, 2025

Next Review DateAug 15, 2026

Key ActionWhen billing, providers must use the most appropriate and current codes and ensure documentation supports that transport meets the policy's medical necessity criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

EITHER conditionMedically necessary logic

ANY of 3Air/Water additional reasons

listedNeonatal indications

ALL requiredTransplant criteria

residence-basedExplicit transplant exclusion

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Medical Necessity Criteria for Ambulance Transport

General ambulance medical necessity

Ambulance transport is considered medically necessary when EITHER of the following conditions is met:

Emergency-related transport: In connection with a medical emergency AND EITHER: transport is to the nearest available provider or facility where the required medical care can be provided; OR transport is from a facility that is not equipped or staffed to treat the patient's specific injury or illness to the nearest appropriate facility where the required medical care can be provided.

Specialized services or bed-confined: The individual requires specialized medical services during transport and close supervision, or is bed-confined (cannot get up from bed without assistance, unable to ambulate, and unable to sit in a wheelchair/chair) AND BOTH: (1) transfer is to the nearest appropriate facility where required medically necessary and covered diagnostic and/or therapeutic services can be provided (e.g., acute care or long-term acute care hospital, acute rehabilitation facility, sub-acute facility, skilled nursing facility, outpatient facility, dialysis center) OR transfer is from an inpatient/outpatient/dialysis center to an individual's home upon completion of required medically necessary and covered diagnostic and/or therapeutic services; AND (2) other means of transport are medically contraindicated or not feasible.

Air/Water ambulance medical necessity

Air/water ambulance transport is considered medically necessary when criteria for ambulance transport are met AND ANY of the following:

Air/water additional reasons: Point of pickup is inaccessible by a ground ambulance; OR great distances or other obstacles make ground transport not feasible to the nearest hospital with appropriate facilities; OR ground ambulance transport would impede timely and appropriate medical care.

Transplant transport

Ambulance transport for a transplant event is considered medically necessary when ALL of the following are met:

Transplant transport criteria: The facility is authorized to perform the transplant for the individual; AND the proposed transplant event is urgent and time critical; AND urgent circumstances prevent prearrangement for an alternative mode of transportation.

Neonatal transport indications

Considered medically necessary for neonatal transport when one or more of the following clinical conditions are present:

Neonatal indications: 1. Gestational age <30 weeks, body weight <2,000 grams, or complicated neonatal course (e.g., perinatal cardiac/respiratory arrest, hemodynamic instability, sepsis, meningitis, metabolic derangement, temperature instability); 2. Requirement for supplemental oxygen exceeding 60%, continuous positive airway pressure (CPAP), or mechanical ventilation; 3. Extrapulmonary air leak, interstitial emphysema, or pneumothorax; 4. Medical emergencies such as seizure activity, congestive heart failure, or disseminated intravascular coagulation; 5. Surgical emergencies such as diaphragmatic hernia, necrotizing enterocolitis, abdominal wall defects, intussusception, suspected volvulus, or congenital heart defects.

Each listed condition is an indication for neonatal transport per policy.

Transplant transport indications

Air transport for transplant is considered medically necessary when either of the following applies:

Transplant indications: 1. Patient has met criteria for brain death and air transport is necessary for organ salvage; 2. Organ and/or organ recipient requires air transport to the transplant center in order to maintain viability of a time-critical transplant.

Applies to organ salvage and time-critical transplant viability situations.

Ambulance transport for a transplant event is considered not medically necessary when the transport is intended solely to allow the participant to live outside the transplant program’s defined driving distance. This exclusion applies whether the transport is to or from the transplant facility and remains in effect even if the transplant program would otherwise accept the patient for care at that distant residence.

When submitting claims, providers must ensure the HCPCS/CPT codes billed are current and effective for the date of service. Deleted codes or codes not effective at the time the service is rendered may not be eligible for reimbursement, and code lists in this policy may not reflect the most recent AMA/CMS updates.

In addition, ambulance transport for a transplant event is considered not medically necessary if the only purpose of transport is participation in a clinical trial. Such transports are excluded from coverage under this policy.

This policy underwent annual review with no changes to the clinical policy statements. No clinical policy statement changes were made during the documented annual reviews.

Codes and Clinical Thresholds

Covered CPT Codes (referenced requirement)mixed

No codes listed

Considered Medically Necessary CodesHCPCSCovered

A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way.
A0380	BLS mileage (per mile).
A0390	ALS mileage (per mile).
A0424	Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review).
A0425	Ground mileage, per statute mile.
A0426	Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS 1).
A0427	Ambulance service, advanced life support, emergency transport, Level 1 (ALS 1- Emergency).
A0428	Ambulance service, basic life support, non-emergency transport (BLS).
A0429	Ambulance service, basic life support, emergency transport (BLS-Emergency).
A0430	Ambulance service, conventional air services, transport, one way (fixed wing).

1–10 of 19

1/2

Glasgow Coma Scale (GCS) thresholds — scene and neurologic

Scene triage thresholdGlasgow Coma Scale (Trauma Score) less than 12

Neurologic consideration thresholdGlasgow Coma Scale score less than 10 (neurologic considerations)

Associated examplesIncludes deteriorating mental status, skull fracture, or presentation suggestive of spinal cord injury per neurologic considerations

Neonatal gestational age and weight criteria

Gestational age thresholdGestational age less than 30 weeks

Birth weight thresholdBody weight less than 2,000 grams

Billing, Authorization, and Documentation Actions for Providers

Prior Authorization

Plan-specific coverage / Prior Authorization

Coverage varies by customer; always verify benefits and prior authorization requirements in the member's benefit plan document and applicable prior authorization rules before scheduling or billing ambulance services.

Coverage varies by customer — refer to the customer's benefit plan document for coverage details.

Prior Authorization

Prior Authorization and Affected Codes

Prior authorization may be required for some ambulance services. Services billed with the HCPCS/Revenue codes listed below are considered medically necessary only when the policy criteria are met; prior authorization requirements depend on the member's specific plan.

Affected HCPCS codes include: A0225, A0380, A0390, A0424, A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0998, S0207, S0208.

Background and Context

Ambulance services encompass the assessment, provision of emergency or specialized medical care, and transport of ill or injured patients by trained personnel using properly licensed ground, air (fixed or rotary wing), or water vehicles. These services include scene triage, stabilization, and interfacility transfer when the level of care or timeliness required cannot be provided by other transport means. Professional society guidance (e.g., scene triage and interfacility air transport criteria) informs clinical indications across trauma, cardiac, neurological, neonatal, obstetric, and other critical conditions.

Key Definitions

Bed-confined — definition

DefinitionUnable to get up from bed without assistance, unable to ambulate, and unable to sit in a wheelchair or chair

Implication for transportConsidered bed-confined status when determining need for ambulance transport under specialized services/bed-confined criteria

DocumentationProvider documentation should support inability to ambulate or self-transfer as described

Medically necessary ambulance transport — definition

Emergency vs specialized servicesMedically necessary ambulance transport meets either emergency-related criteria to the nearest appropriate facility OR specialized services/bed-confined status requiring supervised transport when other means are contraindicated

Air/water add-onAir/water ambulance requires ambulance criteria plus additional reasons (inaccessible pickup point, great distances/obstacles, or ground transport would impede timely care)