CurrentPresbyterian Health PlanPolicy 1.1

Ambulance Services

Defines medical necessity, origin/destination rules, documentation, coding guidance, covered and excluded circumstances for ground and air ambulance transports affecting Presbyterian Health Plan members (commercial, Medicare, and Medicaid where noted).

Policy Summary

PayerPresbyterian Health Plan

PolicyAmbulance Services

Policy CodePolicy 1.1

Change TypeAnnual review — no material changes

Effective DateOct 23, 2024

Next Review DateOct 23, 2024

Key ActionMaintain complete documentation (including physician certification for repetitive services dated within 60 days) demonstrating medical necessity for ambulance transports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CoveredAllowed ground destinations

Acute hospital onlyAir destination restriction

A0430–A0436, A0425–A0429Referenced HCPCS codes

Dual diagnosis reqICD-10 reporting

No PAPA stance for listed codes

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Coverage criteria for ambulance services

Air ambulance inter-facility transfer criteria

Air ambulance (hospital-to-hospital) is covered when ALL of the following requirements are met:

Air ambulance hospital-to-hospital coverage: A ground ambulance transport endangers the beneficiary's health; the transferring hospital does not have the needed hospital or skilled nursing care for the member's illness or injury; the second hospital is the nearest appropriate facility; examples include need for specialized services (burn, cardiac, trauma, critical care); inaccessibility to ground transport for an extended length of time could endanger the member; instability of ground transport (e.g., weather or traffic) makes ground ambulance impractical, impossible, or overly time consuming; air ambulance begun before the member died may be covered for the initial leg if death occurs prior to arrival.

Appropriate Facility and medical reasonableness definitions support these requirements (see dispatch and appropriate facility criteria).

Ground ambulance origin/destination criteria

Ground ambulance transports are covered when ALL program requirements are met and origin/destination match allowed destinations:

Allowed ground destinations: Transport only to/from hospitals (including acute inpatient rehabilitation and Long Term Acute Care), beneficiaries' homes (when within the institution's locality or when returning from an appropriate facility), Critical Access Hospitals (CAH), dialysis facilities for ESRD beneficiaries who require dialysis, Skilled Nursing Facilities (SNF) and from SNF to the nearest supplier of medically necessary services not available at the SNF (including return trip), and to/from covered medical services destinations when transport is less costly than bringing the service to the patient. Physicians' offices are covered only when the ambulance is en route to a covered destination or stops for the member's dire need and immediately continues to the covered destination. High-risk transports must be prescribed by the attending physician when applicable.

Institutional criteria per Social Security Act sections apply; additional dispatch/protocol requirements described in definitions.

General coverage basis

Policy follows CMS National Coverage Policy and CFR guidance for ambulance coverage; no criteria changes in this publication.

Coverage basis: Coverage decisions are based on Social Security Act Section 1862(a)(1)(A) (services must be reasonable and necessary) and applicable Code of Federal Regulations (Title 42 Parts 410, 414, and 424). Providers may submit additional information for cases that do not strictly meet standard criteria for individualized review by a medical director.

References include CMS manuals, CFR Title 42, and related CMS guidance; publication history notes no criteria change.

Ambulance services (ground and air) are not covered when they are not medically necessary. Examples of non-covered circumstances include use of ambulance services as a convenience for the member or family, situations where the member refuses assessment, treatment, or transportation, and any non-emergent or scheduled air ambulance transports. Payment is also excluded when air transport is used even though ground transport poses no threat and the pickup point is accessible by land. When a member is pronounced dead before dispatch, ambulance services are not covered; limited base-rate payment rules apply if death occurs after dispatch and before loading. Non-emergency wheelchair transport and transport to obtain non-covered services are also excluded.

Per Title XVIII Section 1862(a)(1)(A) of the Social Security Act, payment will not be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury. Ambulance services that fail to meet this standard are excluded from payment under this policy.

Non-emergency ambulance transportation is not covered if the service could have been safely and effectively provided at the point of origin (for example, the patient’s residence, SNF, or hospital), even when the patient could only have reached the service by ambulance. The policy reiterates that transport provided solely because the patient cannot otherwise travel does not, by itself, establish medical necessity. Additionally, non-emergency wheelchair-only transport is specifically excluded.

This policy follows federal guidance that coverage is limited to services that are reasonable and necessary under Title XVIII Section 1862(a)(1)(A). Services that are not reasonable and necessary for diagnosis or treatment — including ambulance services that do not meet clinical medical-necessity criteria — are considered not medically necessary and are not payable.

Coding and billing guidance

HCPCS CodesHCPCS

A0430	Air ambulance service, transport, one-way, fixed wing (FW)
A0431	Air ambulance service, conventional air services, transport, one-way, rotary wing (RW)
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile
A0428	Ambulance service, basic life support, non-emergency transport (BLS)
A0425	Ambulance ground mileage, per statute mile (BLS/ALS)
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS1-emergency)
A0429	Ambulance service, basic life support, emergency transport (BLS emergency)
A0433	Advanced life support, level 2 (ALS2)

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ICD-10 Secondary Diagnosis Codes (required as secondary)ICD-10

Z74.01	Bed Confinement status (secondary diagnosis must be reported)
Z74.3	Need for continuous supervision (use to denote cardiac/hemodynamic monitoring required en route)
Z78.1	Physical restraint status (patient safety; danger to self/others)
Z99.89	Dependence on other enabling machines and devices (e.g., continuous IV fluids, active airway management)
Z76.89	Persons encountering health services in other specified circumstances (used when transported but did not require ambulance crew services)

Codes exempted from prior authorization per policy historyHCPCSCovered

A0430	Ambulance service, advanced life support, non-emergency transport, level 1 (A0430 listed as not requiring PA)
A0431	Ambulance service, advanced life support, emergency transport (A0431 listed as not requiring PA)
A0435	Fixed wing air ambulance transport, (listed as not requiring PA)
A0436	Rotary wing air ambulance transport, (listed as not requiring PA)
A0425	Ground mileage (listed as not requiring PA)
A0426	Ambulance service, advanced life support, non-emergency transport (duplicate mentions in history; listed as not requiring PA)
A0427	Ambulance service, transportation, specialty care (listed as not requiring PA)
A0428	Ambulance service, basic life support, non-emergency transport (listed as not requiring PA)
A0429	Ambulance service, basic life support, emergency transport (listed as not requiring PA)
A0433	Advanced life support, level 2 (listed as not requiring PA)

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Physician certification recency for repetitive services

RequirementPhysician certification for repetitive non-emergent transports must be dated no earlier than 60 days before the date of service.

Responsible partyAmbulance supplier must obtain and retain the physician certification as part of required documentation.

Reference guidanceSee Novitas (retired) LCD L35162 for circumstances when providers other than a physician may provide a certificate for non-repetitive nonemergent transports.

Documentation contextCertification is one element of documentation used to demonstrate medical necessity; suppliers must furnish it if requested.

Provider responsibilities, authorization, and documentation

Prior Authorization

Prior authorization guidance

Providers should follow applicable prior authorization processes and CMS guidance. Although certain non-emergent ground ambulance HCPCS codes are not listed on PHP's prior authorization grid, check payer-specific prior authorization portals or instructions for any member-specific or plan-specific PA requirements before rendering services.

Follow PHP and payer portals for PA requests where applicable
Refer to current CMS guidance, LCDs/NCDs, and PHP publication history for PA policy changes

Documentation Required

Required documentation

Ambulance suppliers must maintain and, upon request, furnish complete and accurate documentation demonstrating medical necessity. Required documentation may include physician certification of medical necessity (for repetitive non-emergent transports certification dated no earlier than 60 days prior to service), a detailed description of the patient’s condition at time of transport, point of pickup, miles/dispatch record, and for hospital-to-hospital transports, the specific treatment or specialist requested.

Physician certification of medical necessity (repetitive services: dated ≤60 days before service)
Detailed description of patient condition consistent with supporting records (symptoms, functional status, safety issues, monitoring)
Point of pickup, number of miles, and dispatch record
For hospital-to-hospital transports, indicate specific treatment or specialist
Bed confinement is not sole criterion; to document bed confinement, show inability to (1) get up without assistance, (2) ambulate, and (3) sit in a chair/wheelchair

Documentation Required

Documentation expectations

When PHP follows specific external guidelines (LCDs, NCDs, MCG, NCCN, CMS manuals), providers are expected to maintain or have access to those source documents and any supporting medical records for review. Failure to provide documentation demonstrating that ambulance services were reasonable and necessary per Social Security Act Section 1862(a)(1)(A) and applicable federal regulations may result in denial of payment.

Maintain access to applicable LCDs/NCDs, CMS IOM, and other guideline sources relied upon for coverage determinations
Be prepared to produce supporting medical records upon request to substantiate medical necessity
Lack of documentation showing services were reasonable and necessary is a trigger for denial

Denial Risk

Triggers for denial

Any ambulance transport that does not meet medical necessity criteria — for example, non-emergent transport that could have been safely and effectively provided at the point of origin — may be denied. PHP will not pay for items or services that are not reasonable and necessary under applicable law and policy.

Non-emergency transports where the service could have been safely provided at point of origin may be non-covered
Ambulance services used solely for convenience or when the member refuses assessment/transport are excluded

Policy definitions

Medical Necessity for Ambulance Transfer

DefinitionThe member's condition is such that other means of transportation are contraindicated and would endanger the eligible recipient's health.

Clinical implicationAmbulance transfer is appropriate when non-ambulatory or clinical instability makes other transport unsafe.

DocumentationSuppliers must document the condition, symptoms, functional status, and any safety issues to substantiate that other transport means are contraindicated.

Related exclusionsTransfers used as convenience, or when ground transport poses no threat and is accessible, are not covered.

Emergency Air or Ground Ambulance Services — sudden onset severity

DefinitionSudden onset of symptoms of sufficient severity that a reasonable layperson could expect serious jeopardy, serious impairment of bodily functions, serious dysfunction of any bodily organ or part, or disfigurement without immediate attention.

Layperson standardAssessment uses a reasonable layperson's expectation of harm from absence of immediate medical attention.

Applies toEmergency air or ground ambulance services provided after such sudden onset events.

Documentation needsRecord symptoms and severity at scene to support emergency transport determination.

Appropriate Facility — acute care hospital & nearest appropriate facility for air transport

Acute care hospitalAn appropriate facility is an acute care hospital generally equipped to provide needed hospital or skilled nursing care with a physician or specialist available.

Nearest appropriate facility requirementAir transport to a more distant facility requires clear evidence that the distant hospital is the nearest appropriate facility (e.g., need for specialized services or no beds at nearest hospital).

Justifying circumstancesExamples include need for higher level trauma care or specialized services only available at the more distant hospital, or lack of beds at the nearer hospital.

PresumptionAll duly licensed acute care hospitals are presumed appropriate; clear evidence is required to justify a more distant air transfer.

Ambulance Services (per Social Security Act) — statutory references

Statutory reference — ambulance servicesTitle XVIII of the Social Security Act, Section 1861(s)(7) — Ambulance Services.

Statutory reference — bona fide emergency servicesTitle XVIII of the Social Security Act, Section 1861(v)(1)(K)(ii) — Bona Fide Emergency Services.

Medical necessity standardTitle XVIII Section 1862(a)(1)(A): No payment for items or services that are not reasonable and necessary for diagnosis or treatment.

Regulatory citationsCFR Title 42, Part 410 (§410.40, §410.41) and related sections cited for coverage and supplier requirements (Title 42 last amended 09/24/2024).

OpenPayer

Ambulance Services

Coverage criteria for ambulance services

Coding and billing guidance

Provider responsibilities, authorization, and documentation

Policy definitions

Background and scope

Policy revision history