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Review Criteria
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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.
No material clinical or coverage changes.
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
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:
Exclusions / Not Covered
Non-Ambulance Exclusion
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.
Provider Actions and Authorization Requirements
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.
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 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.
Coding
| No codes listed |
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.
Medicare Determinations
| NCD name | Number | Type | Effective date |
|---|---|---|---|
| Ambulance Coverage (Non-Emergency) | NCD |
Revision History
Effective date of the criteria
Last revision/review date
Planned next review date
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