CurrentKaiser PermanentePolicy 01-17

Review Criteria

Defines medical necessity, origin/destination requirements, covered destinations, authorization review cadence, and exclusions for non-emergency ambulance transportation for the Kaiser Permanente Georgia region, based on CMS ambulance coverage guidance.

Policy Summary

PayerKaiser Permanente

PolicyReview Criteria

Policy CodePolicy 01-17

Change TypeReviewed/Revised

Effective DateFeb 7, 2020

Next Review DateMar 14, 2025

Key ActionAuthorizations for non-emergency ambulance transport must meet the medical necessity and origin/destination criteria; open authorizations may be reviewed every 30 days for continued appropriateness.

POLICY UPDATE CHANGES

No material clinical or coverage changes.

30Authorization review cadence (days)

3Required elements to define bed-confined

Coverage Summary

Overview: This policy (Policy No. 01-17) defines review criteria for Non-emergency ambulance transport in the Kaiser Permanente Georgia region. Coverage stance: covered_with_criteria. It is effective 2020-02-07, last reviewed 2024-03-14, and next review is scheduled for 2025-03-14. The subject is Non-emergency ambulance transport review criteria and the document is current guidance used to determine medical necessity for ambulance services.

Medical Necessity for Non-Emergency Ambulance Transport

Ambulance transport in non-emergency situations is covered when ALL of the following medical necessity and origin/destination criteria are met:

ALL of the following

Bed-confined defined as
- Be confined to bed; unable to get up from bed without assistance
- Unable to walk
- Unable to sit in a chair or a wheelchair
Or need vital medical services during the trip that are only available in an ambulance (example: administration of medications or monitoring of vital functions)
Use of other means of transportation would endanger the beneficiary's health
Beneficiary will receive medically necessary services at the destination
Origin and Destination Criteria must be met (see Destination list)
Lack of alternative transportation does NOT create medical necessity

Authorization Review

Ongoing authorization review rule:

Open authorizations may be reviewed every 30 days to determine continued medical appropriateness and medical necessity

Exclusions / Not Covered

Transportation by car, taxi, bus, gurney van, wheelchair van, minivan, or other transportation (other than a licensed ambulance) is not covered even if it is the only way to travel to a facility

Non-Ambulance Exclusion

Ambulance services that do not meet the criteria: condition does not require services only a licensed ambulance can provide; use of other transport would not endanger health; or no medically necessary services will be received at destination

We will not cover ambulance services in any other circumstances, even if no other transportation is available.

Definitions and Covered Destinations

Definitions: Bed-confined — beneficiary meets all three of the following: be confined to bed and unable to get up from bed without assistance; unable to walk; and unable to sit in a chair or a wheelchair. The term is not synonymous with bed rest or nonambulatory and bed-confinement alone is neither sufficient nor necessary to determine Medicare ambulance coverage; it is one element considered in the determination.

Origin and Destination Criteria: Covered destinations follow CMS origin/destination guidance and include locations such as hospital (including outpatient procedures and LTAC), skilled nursing facility/rehab, dialysis for dialysis care, inpatient hospice, outpatient surgery centers, MD office for wound or post-surgical care, LTAC, and home in certain circumstances. Ambulance transport is covered only when both the medical necessity criteria and these origin/destination requirements are met.

Covered destinations per CMS

Hospital (includes outpatient procedures & LTAC)Listed as a covered destination

SNF / RehabIncluded as a covered destination

DialysisCovered for dialysis care

Inpatient HospiceListed as a covered destination

MD office (wound/post‑surgical care)Included as covered destinations for specific services

Outpatient Surgery CentersIncluded (hospital outpatient surgery center / outpatient procedures)

HomeCovered in certain circumstances (series or DOS ranges noted)

Provider Actions and Authorization Requirements

Prior Authorization

Authorization requirement and periodic review

Authorizations for non-emergency ground ambulance transport must meet the policy's medical necessity and origin/destination criteria. Open authorizations may be reviewed for continued appropriateness and medical necessity every 30 days.

Documentation Required

Document bed-confined status or need for ambulance-only services

Document that the beneficiary is bed-confined by recording all three elements: unable to get up from bed without assistance; unable to walk; and unable to sit in a chair or wheelchair. Alternatively, document that the beneficiary requires vital medical services during the trip that are only available in an ambulance (for example, administration of medications or monitoring of vital functions).

Unable to get up from bed without assistance
Unable to walk
Unable to sit in a chair or a wheelchair
Or documentation that vital services during transport only available in an ambulance are required (e.g., medication administration, monitoring of vital functions)

Denial Risk

Denial if criteria not met

Claims or authorizations may be denied if the origin/destination requirements or the medical necessity criteria are not met. The mere lack of alternative transportation does not constitute medical necessity and is not sufficient to prevent denial.

Background and Evidence

Background: This review criterion was developed based on CMS guidance regarding Ambulance Coverage (Non-Emergency) and has been adopted into the KP Georgia Medicare Benefits Manual. The policy describes when non-emergency ground ambulance transportation is a covered benefit — specifically when the beneficiary’s condition requires services that only a licensed ambulance can provide, use of other transportation would endanger the beneficiary’s health, and medically necessary services will be received at the destination. The purpose of the policy is to guide utilization management determinations of ambulance appropriateness and to support authorization and claim decisions.

Evidence: Source guidance: CMS Ambulance Coverage guidelines (BP102c10 referenced) — the criterion in this document is directly based on CMS guidance as adopted in the KP Georgia Medicare Benefits Manual.

NCD name	Number	Type	Effective date
Ambulance Coverage (Non-Emergency)		NCD