Sierra Health and Life Ambulance Coverage & PA

Coverage Summary

This policy (Part 1 of 2) defines medical necessity and coverage criteria for both emergency and non-emergency ground and air ambulance services (including rotary and fixed wing air ambulances) for UnitedHealthcare Commercial and Individual Exchange plans. It lists covered indications and limitations, applicable HCPCS and revenue codes, definitions (for example Air Ambulance and Medically Necessary), and cites clinical and regulatory guidance informing coverage decisions. Prior authorization is required for non‑emergency Air Ambulance transport and may be required for non‑emergency ground ambulance depending on the member's specific plan.

Medical-Necessity Criteria

Emergency Air Ambulance - Medically Necessary

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

ALL of the following

The member's medical condition requires immediate transportation that cannot be provided by ground ambulance and a delay in transportation time may endanger the member's life or seriously endanger the member's health
Examples: ground transport times are excessive (i.e., 30-60 minutes or longer); weather/traffic make ground impractical; pickup point inaccessible by ground
The member's destination is the nearest acute care hospital that can meet the member's needs
ONE of the following
- Services are requested by police or medical authorities at the site of an Emergency
- Advanced or basic life support is required during transportation

Emergency Air Ambulance - Not Medically Necessary

Emergency Air Ambulance services are not considered Medically Necessary for all other indications.

Any air ambulance transport not meeting the Medically Necessary criteria listed above

Emergency Ground Ambulance - Medically Necessary

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

ALL of the following

ALL of the following
- To one of
  - The nearest acute hospital that can provide services appropriate to the covered person's illness or injury
  - The nearest neonatal special care unit for newborn infants when required level of care is needed
  - A hospital that provides a required higher level of care that was not available at the original hospital
- A delay in transportation time may endanger the member's life or seriously endanger the member's health

Emergency Ground Ambulance - Medically Necessary without transport

Emergency ground ambulance services without ground transportation are considered Medically Necessary when:

Treatment is rendered by the Emergency ground ambulance personnel at the scene

Emergency Ground Ambulance - Not Medically Necessary

Emergency ground ambulance transportation is not considered Medically Necessary for all other indications.

Any emergency ground ambulance transport that does not meet the Medically Necessary criteria above

Non-Emergency Ambulance (Ground and Air) - Covered when ONE of the following is met

Coverage includes non-Emergency ambulance transportation between facilities only when transport meets one of the following:

ANY of the following

From an out-of-network hospital to the closest network hospital when Covered Health Care Services are required
To the closest network hospital that provides the required Covered Health Care Services that were not available at the original Hospital
From a Short-Term Acute Care Facility to the closest network Long-Term Acute Care Facility (LTAC), network inpatient rehabilitation facility, or other network Sub-Acute Facility where the required Covered Health Care Services can be delivered

Non-Emergency Ambulance - Benefit level depends on origin

The applicable benefit level for eligible non-Emergency ambulance transportation depends on member pick-up location (origin):

ANY of the following

If member is inpatient and transported from a hospital to another hospital or inpatient facility, coverage levels may vary
If member is in a sub-acute setting and transported to an outpatient facility and back, coverage is under the benefits that apply to that sub-acute setting (example: skilled nursing facility transports covered under SNF/IRF section of the Certificate of Coverage)

Not Medically Necessary / Exclusions

Claims may be denied when services fall outside the stated coverage criteria — for example when the transport mode is inappropriate given the clinical criteria (including use of air transport that does not meet air ambulance indications), the provider is not properly licensed to perform the ambulance service, the transport is non‑ambulance (e.g., taxi, rideshare, commercial/private aircraft or police car), the transport is primarily for convenience, or when the transport violates required notification or benefit‑specific rules. Prior authorization requirements for non‑emergency air (and plan‑dependent ground) must also be met.

Coding

Ambulance Modifiers (origin/destination)Modifier

D	Diagnostic or therapeutic site other than P or H when these are used as origin codes
E	Residential, domiciliary, custodial facility (other than 1819 facility)
G	Hospital-based ESRD facility
H	Hospital
I	Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport
J	Freestanding ESRD facility
N	Skilled nursing facility
P	Physician's office
QL	Patient pronounced dead after ambulance called (must be billed in place of origin/destination combo)
R	Residence

1–10 of 12

1/2

Air Ambulance HCPCS/CodesHCPCS

A0430	Ambulance service, conventional air services, transport, one way (fixed wing)
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile
S9960	Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)
S9961	Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)
T2007	Transportation waiting time, air ambulance and nonemergency vehicle, one-half (1/2) hour increments

Ground/Other Ambulance HCPCS/CodesHCPCS

A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
A0380	BLS mileage (per mile)
A0382	BLS routine disposable supplies
A0384	BLS specialized service disposable supplies; defibrillation
A0390	ALS mileage (per mile)
A0392	ALS specialized service disposable supplies; defibrillation
A0394	ALS specialized service disposable supplies; IV drug therapy
A0396	ALS specialized service disposable supplies; esophageal intubation
A0398	ALS routine disposable supplies
A0420	Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments

1–10 of 23

1/3

Ambulance Revenue CodesRevenue

0540	Ambulance-General Classification
0541	Ambulance-Supplies
0542	Ambulance-Medical Transport
0543	Ambulance-Heart Mobile
0544	Ambulance-Oxygen
0545	Ambulance-Air Ambulance
0546	Ambulance-Neonatal Ambulance Services
0547	Ambulance-Pharmacy
0548	Ambulance-EKG Transmission
0549	Ambulance-Other Ambulance

Regulatory / Reference Codes citedmixed

42 CFR 414.605	Definitions; Fee Schedule for Ambulance Services
42 CFR 460.100	Emergency Care

Provider Actions

Prior Authorization

Prior authorization for non-emergency Air Ambulance

Prior authorization is required for non-Emergency Air Ambulance transport.

Prior Authorization

Prior authorization for non-emergency ground ambulance (plan dependent)

Certain plans may require prior authorization for non-Emergency ground ambulance transport; refer to the member specific benefit plan document.

Documentation Required

Medical records documentation for reviews

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage; reviewers may request records. Benefit coverage is determined by the member specific benefit plan document and applicable laws.

Background, Evidence & Definitions

This policy explains how medical necessity is determined for ambulance services (ground and air), provides definitions of key terms (for example rotary and fixed wing Air Ambulance and Emergency), and references field triage and national EMS/air‑medical guidance to inform coverage decisions. It cites evidence and expert position statements — including NAEMSP/ACEP/AMPA joint guidance and AMPA statements on STEMI and acute stroke — and clinical studies that examine transport times, outcomes, and scenarios where air transport may be appropriate (for example remote or time‑sensitive cases). The purpose is to align coverage determinations with generally accepted standards of medical practice and regional EMS/triage policy.

Citation	Key finding
Rhodes et al. 2023	Retrospective single-center trauma registry showing prolonged transport times associated with worse GCS and increased deaths; supports direct HEMS launch in rural/time-critical scenarios.
Kunte et al. 2021	Retrospective stroke transfer study: air transfers faster when distance >40 miles; transfer mode not independently associated with outcome when controlling for therapies.
Stewart et al. 2021	Retrospective cohort: helicopter transfer associated with decreased 72-hour mortality for transfers <90 miles; mixed findings and potential overtriage.
NAEMSP/ACEP/AMPA Joint Position (Lyng et al. 2021a)	Defines three primary goals for air medical transport and emphasizes GEMS preference when appropriate.
AMPA Position (2012, 2004/2012 update)	Supports air transport for ACS/STEMI and acute stroke when timely interventions are needed and not available locally; medical necessity determination by requesting provider.

Term	Definition
Air Ambulance	Medical transport by rotary wing (RW) or fixed wing (FW) aircraft as defined in 42 CFR 414.605.
Rotary wing Air Ambulance (RW)	Transportation by a helicopter certified as an ambulance and such services and supplies as may be Medically Necessary.
Fixed wing Air Ambulance (FW)	Transportation by a fixed wing aircraft certified as an ambulance and such services and supplies as may be Medically Necessary.
Medically Necessary	Services that are in accordance with Generally Accepted Standards of Medical Practice, clinically appropriate, not mainly for convenience, and not more costly than an alternative providing equivalent results.
Emergency	A condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate medical attention to result in placing health in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.
GEMS	Ground Emergency Medical Services.

Medicare Determinations

Name	Type/Number	Effective Date
Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services	NCD

Revision History

01/01/2026template_updateLatest

Template Update: Created shared policy version to support application to Oxford plan membership and archived previous policy versions MP.001.23 and TRANSPORT 002.32

OpenPayer

Ambulance Services – Commercial and Individual Exchange Medical Policy