ModifiedColorado Rocky Mountain Health PlansPolicy CS003.T

Ambulance Services (Emergency and Non-Emergency, Ground and Air)

Governs medical necessity, coverage, coding, prior authorization, and documentation expectations for emergency and non-emergency ambulance transport (ground and air) for Colorado Rocky Mountain Health Plans members; affects providers requesting reimbursement for ambulance services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyAmbulance Services (Emergency and Non-Emergency, Ground and Air)

Policy CodePolicy CS003.T

Change TypeDefinitions addedreferences updatedprevious version archived

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization when required for non-emergency air ambulance transports and follow plan-specific prior-authorization processes.

SourceLink

POLICY UPDATE CHANGES

Added definition of 'Independent Freestanding Emergency Department'.

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version CS003.S.

1explicit definition added

Required (non-emergency air)prior auth requirement

40+listed applicable codes

Other modes preferredcommon exclusion

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Coverage Criteria for Ambulance Services

Emergency Air Ambulance - Medical Necessity

Emergency Air Ambulance services are considered Medically Necessary when ALL of the following are present:

Air EMS medical necessity: Member's medical condition requires immediate transportation that cannot be provided by ground ambulance and a delay in transportation time may endanger life or seriously endanger health

Examples include excessive ground transport times (i.e., ~30–60 minutes or longer), weather or traffic making ground transport impractical or impossible, or pickup point inaccessible by ground.

Destination is the nearest acute care hospital that can meet the member's needs

Request/level of care: Either services are requested by police or medical authorities at the site of an emergency OR advanced or basic life support is required during transportation

Emergency Ground Ambulance - Medical Necessity

Emergency ground ambulance services are considered Medically Necessary when ALL of the following are present:

Ground EMS immediate transport: Member's medical condition requires immediate transportation to the nearest acute hospital that can provide appropriate services, or to the nearest neonatal special care unit for newborns, or to a hospital that provides a required higher level of care not available at the original hospital

Delay hazard: A delay in transportation time may endanger the member's life or seriously endanger the member's health

Level of care required: Advanced or basic life support is required during transportation

Emergency Ground Non-Transport

Emergency ground ambulance services without ground transportation (treatment at scene) are considered medically necessary when:

On-scene treatment: Treatment is rendered by emergency ground ambulance personnel at the scene

Non-Emergency Ambulance Coverage

Non-Emergency Ambulance (Ground and Air) coverage includes interfacility transports when ONE of the following is met:

Non-emergency transfer reasons: From an out-of-network hospital to the closest network hospital when Covered Health Care Services are required; OR to the closest network hospital or facility that provides required Covered Health Care Services that were not available at the original hospital or facility; OR from a Short-Term Acute Care Facility to the closest network LTAC, network inpatient rehabilitation facility, or other network Sub-Acute Facility where the required Covered Health Care Services can be delivered

Transport must be by a licensed ambulance service (ground or air) as determined appropriate by the plan.

Air Medical Transport Indications

Use air medical services when one or more of the following applies, following field triage and professional judgment:

High-risk injury patterns: Penetrating injuries to head, neck, torso, or proximal extremities; skull deformity or suspected skull fracture; suspected spinal injury with new motor or sensory loss; chest wall instability, deformity, or suspected flail chest; suspected pelvic fracture; crushed, degloved, mangled, or pulseless extremity; amputation proximal to wrist or ankle; active bleeding requiring tourniquet or wound packing with continuous pressure.

From National Expert Panel on Field Triage (high-risk injury patterns).

Physiologic criteria: Unable to follow commands (motor GCS < 6); respiratory rate < 10 or > 29 breaths per minute; respiratory distress or need for respiratory support; room air SpO2 < 90%; age-specific hypotension thresholds (age 0–9: SBP < 70 + 2×age; age 10–64: SBP < 90 or heart rate greater than SBP; age ≥ 65: SBP < 110 or heart rate greater than SBP).

From National Expert Panel on Field Triage (physiologic criteria).

Mechanism and EMS judgment: High‑risk mechanisms (e.g., ejection, significant intrusion, fall >10 ft, pedestrian or bicyclist struck) or EMS judgment factors such as anticoagulant use, pediatric/geriatric considerations, suspected abuse, pregnancy, burns, and high-resource needs.

Ambulance services will be denied when provided by a provider that is not properly licensed or when another mode of transportation is appropriate. Air Ambulance transports that do not meet the Air Ambulance covered indications are specifically excluded. Transport solely for member convenience or preference (for example, wanting to be at a particular hospital for nonmedical reasons or using ambulance for a routine service when medically able to use another mode) is also not eligible for coverage.

Studies and systematic reviews identify potential overtriage when helicopter emergency medical services (HEMS) are used for patients with minor injuries and normal vital signs. One single-center review found that 21.7% of scene-transported HEMS patients were discharged within 24 hours, and many of these patients had no prehospital hypotension and required minimal interventions, suggesting HEMS may have been unnecessary. Systematic reviews of nonrandomized studies show heterogeneous results and selection bias, underscoring the need to reserve HEMS for situations meeting documented clinical criteria rather than resource availability alone.

This Medical Policy is provided for informational purposes to assist with benefit interpretation and administration. It does not constitute medical advice and is intended to be used alongside independent professional clinical judgment and applicable federal, state, or contractual benefit plan requirements.

Air Ambulance services are considered medically necessary only when the specific emergency criteria listed in this policy are met (for example, when ground transport is impractical or would dangerously delay care). Air Ambulance services are not medically necessary for indications other than the listed emergency criteria. The policy distinguishes emergency transport (immediate, time-sensitive transfers to the nearest appropriate acute care or specialized unit) from non-emergency transport (interfacility transfers or routine transports), and non-emergency air transports generally require prior authorization and are covered only when policy conditions are satisfied.

Scene deployment of HEMS for patients who are likely to be discharged within 24 hours, who have no prehospital hypotension, and who require minimal interventions should be carefully considered. Evidence shows a notable proportion of air-transported trauma patients are discharged early, which may indicate overtriage; when clinical presentation suggests low acuity, ground resources or alternative transport should be preferred to avoid unnecessary air transports.

Coding and Billing Codes

Provider Actions, Authorization & Documentation

Documentation Required

Medical records documentation

Medical records may be required to determine whether the member meets clinical criteria for coverage. Retain and make available documentation used for reviews (including clinical assessments, transport records, treating and receiving provider notes, and the Certificate of Medical Necessity when applicable) as coverage is governed by federal, state, or contractual requirements and documentation alone does not guarantee coverage.

Include clinical rationale, vital signs, transport modality considered, and why alternate transport was inappropriate.
Keep documentation for the timeframe required by plan or law; submit upon request for claim or prior authorization review.

Note

Reference governing benefit terms / Conflicts

Follow applicable federal, state, or contractual benefit plan requirements when determining coverage and prior authorization obligations. This policy is informational; if plan-specific terms conflict with this guidance, the governing benefit terms control.

Reference the member’s plan documents and applicable state/federal mandates before approving or performing transport.

Background and Rationale

Ambulance transport (ground, air, or water) is intended to be used when it is the only safe means to get a member to the nearest appropriate care facility due to the severity or nature of illness or injury. Emergency air transport is reserved for situations where ground transport is impractical or would endanger life or seriously endanger health (examples include excessive ground transport times of approximately 30–60 minutes or longer, inaccessible pickup points, or weather/traffic conditions that make ground transport impractical).

Definitions

inv-30: Air Ambulance — definition for air ambulance (rotary or fixed wing certified as ambulances per 42 CFR 414.605)

DefinitionMedical transport by rotary wing (helicopter) or fixed wing aircraft certified as ambulances per 42 CFR 414.605

Rotary wing (RW)Transportation by a helicopter that is certified as an ambulance and such services and supplies as may be Medically Necessary

Fixed wing (FW)Transportation by a fixed wing aircraft that is certified as a fixed wing Air Ambulance and such services and supplies as may be Medically Necessary

inv-31: Medically Necessary — definition of medically necessary used by the policy

Core definitionHealth care services that are: in accordance with Generally Accepted Standards of Medical Practice; clinically appropriate in type, frequency, extent, service site, and duration; not mainly for the member's convenience; and not more costly than an alternative at least as likely to produce equivalent results