ModifiedUnitedHealthcarePolicy CS003KY.09

Ambulance Services (Kentucky)

Medical policy governing coverage criteria for ambulance services (air and ground) for UnitedHealthcare Community Plan members in Kentucky, including medical necessity criteria and definitions that apply to emergency transport.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (Kentucky)

Policy CodePolicy CS003KY.09

Change TypeRevised definitions and updated clinical evidence

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionDocument and justify medical necessity for air or ground ambulance transport, including completion of a Certificate of Medical Necessity when appropriate.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Emergency Health Care Services' and updated Clinical Evidence and References sections to reflect the most current information.

Kentucky-onlystate-specific

Emergency criteria (air)air criteria

Emergency criteria (ground)ground criteria

Air & ground listcodes listed

38trials cited

Coverage and Medical Necessity Criteria

Emergency Air Ambulance — Medically Necessary

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

Air ambulance overall

Examples supporting ground inadequacy: When ground transport times are excessive (i.e., 30-60 minutes or longer); or when weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming; or when the pickup point is inaccessible by ground ambulance.
Final required condition: 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 — Medically Necessary

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

Ground ambulance overall: Member's medical condition requires immediate transportation to the nearest appropriate acute hospital (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); a delay in transportation time may endanger the member's life or seriously endanger the member's health; and Advanced or basic life support is required during transportation.

Includes emergency ground ambulance response without transport when treatment is rendered on scene by ambulance personnel.

Triage and transport criteria (guideline-derived)

Transport and triage recommendations and criteria from national guidance and professional organizations

Primary patient-centered goals for air medical services: Air medical services should be used for initiation or continuation of advanced or specialty care not otherwise available locally; expedited delivery to definitive care for time-sensitive interventions; or extraction/evacuation/rescue from environments inaccessible to ground resources.

From NAEMSP/ACEP/AMPA joint statement (2021).

High-risk field triage criteria: Patients meeting any high-risk criteria — including specified anatomic injury patterns (e.g., penetrating injuries to head/neck/torso/proximal extremities; suspected skull fracture; suspected spinal injury with new motor or sensory loss; chest wall instability/flail chest; suspected pelvic fracture; crushed/degloved/mangled/pulseless extremity; amputation proximal to wrist or ankle; active bleeding requiring tourniquet or wound packing) or abnormal physiologic/mental status thresholds (unable to follow commands: motor GCS < 6; respiratory rate < 10 or > 29; respiratory distress or need for respiratory support; room air SpO2 < 90; age-specific systolic BP thresholds and HR > SBP criteria) — should be triaged to the highest-level trauma center with consideration of air medical services.

From National Expert Panel on Field Triage (2022).

Air and ground emergency ambulance services that do not meet the specific medical necessity criteria listed in this policy are not considered Medically Necessary. Examples include transports where ground ambulance can meet the patient’s needs in a timely manner, the pickup point is accessible by ground, the destination is not the nearest appropriate acute care facility, or ALS/BLS is not required during transport.

For informational purposes only: ambulance transportation is a service and therefore not subject to FDA regulation. FDA approval status is not a basis for coverage determinations for ambulance transport.

Both Emergency Air Ambulance and Emergency ground ambulance transports are considered Medically Necessary only when the multi-part criteria in this policy are satisfied. Transport by air or ground that does not meet those listed emergency criteria (for example, when timely ground transport is available and appropriate, or when ALS/BLS is not required) is not considered Medically Necessary.

The clinical evidence summarized in this policy does not demonstrate a consistent mortality or disability benefit for helicopter (HEMS) transport over ground (GEMS) across studied populations. A Cochrane-style review of nonrandomized trials found heterogeneous results and insufficient quality to produce a reliable pooled estimate, with some inter-facility transfer studies suggesting possible benefit but overall low-quality evidence. A prospective single-center observational stroke study similarly did not find reduced mortality or improved functional outcomes with HEMS compared with GEMS.

Procedure, Modifier, and Revenue Codes

When ground transport times are excessive

Excessive Ground Transport Time Threshold

Provider Responsibilities, Documentation, and Denial Risk

Prior Authorization

Air medical transport requires clinical justification

Air medical transport requires clinical justification. Emergency air ambulance should be used only when the patient’s condition meets clinical criteria for air transport — for example, when initiation/continuation of advanced or specialty care is needed that is not available locally, when expedited delivery for time-sensitive intervention is required, or when ground access is impractical or impossible (e.g., remote location, impassable roads, excessive ground transport time). Ground EMS (GEMS) is preferred when GEMS resources can meet the patient’s need for critical care expertise and timely transport; GEMS clinicians should cancel air response when air transport would not meet one of the primary patient-centered goals or would place crews at undue risk.

Air transport must be clinically justified at the time of request.
Air transport appropriate for initiation/continuation of specialty care, time-sensitive interventions, or extraction from inaccessible locations.
GEMS is preferred when it can safely and timely meet clinical needs.

Background and Rationale

Air and ground ambulance transport are time-sensitive interventions used to rapidly move patients to an appropriate level of care. This policy exists to guide when expedited transport modalities are appropriate — emphasizing that air transport should be reserved for situations where ground resources cannot provide timely or necessary care, and that ground transport is preferred when it can meet the patient’s critical care and time-sensitive needs.

Key Definitions

Air Ambulance definition

Regulatory definitionAir Ambulance: medical transport by rotary wing or fixed wing aircraft certified as ambulance 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

Emergency definition

Prudent layperson standardAn Emergency is a medical condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate medical attention to result in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part

Scope includes severe pain

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (Kentucky)

Policy CodePolicy CS003KY.09

Change TypeRevised definitions and updated clinical evidence

Effective DateJuly 1, 2025

Next Review DateN/A

Key ActionDocument and justify medical necessity for air or ground ambulance transport, including completion of a Certificate of Medical Necessity when appropriate.

SourceLink

On This Page

Moderate-risk considerations:

Patients with moderate-risk mechanism of injury (e.g., high-risk auto crash, rider separated from vehicle with significant impact, pedestrian/bike significant impact, fall >10 ft) or EMS judgment factors (low-level falls in children/elderly, anticoagulant use, suspected child abuse, pregnancy, burns, high-resource needs) warrant consideration for higher-level care and possible air transport when appropriate.

From National Expert Panel on Field Triage (2022).

Preference for ground when appropriate: Ground EMS (GEMS) transport is preferred when the patient's need for critical care expertise and timely transport to definitive care can be met with ground resources; GEMS clinicians should be empowered to cancel air medical response if continuing would place crews at undue risk or would not align with the primary goals for air transport.

From NAEMSP/ACEP/AMPA joint statement (2021).

Prior Authorization

Ground preferred when adequate

When ground transport can safely and timely meet the patient’s needs, ground ambulance is the preferred modality. If evaluation on scene or updated clinical information indicates ground transport is adequate, the air response should be cancelled.

Prefer ground transport when GEMS clinicians can provide required critical care and timely transport.
Cancel air medical response if ground resources are adequate or if continuing air response places crews at undue risk.

Documentation Required

Documentation of medical necessity

Document the individualized medical necessity decision clearly in the medical record and on transport documentation. Medical necessity determinations must be based on an individualized assessment of the patient’s medical needs and include clinical findings, rationale for chosen transport modality, estimated ground transport times or barriers, destination facility capability, and any time-sensitive interventions required.

Record clinical findings supporting immediate transport and why ground transport is inadequate (e.g., estimated ground time, access barriers, need for specialty care).
Document the destination and why it is the nearest facility able to meet the patient’s needs.
Include who made the decision (requesting authorized provider, receiving physician, or transport medical director) and time of decision.

Prior Authorization

Transport modality escalation

Transport modality should escalate based on clinical need and operational constraints: prefer ground when it can provide timely, appropriate care; use air when ground cannot meet time, access, or specialty-care requirements. Decisions to escalate to air transport must be justified in the record and align with the three primary patient-centered goals for air medical use.

Escalate to air when ground transport times are excessive or access is impossible/impractical.
Escalate for time-sensitive interventions or when specialty care initiation/continuation is required and unavailable locally.
Operational considerations (weather, crew/aircraft safety) must be documented and may warrant cancellation or modality change.

Includes acute symptoms of sufficient severity (including severe pain)

ApplicabilityDefinition applies to Covered Person and, for pregnant women, the health of the woman or her unborn child

Medically Necessary definition

Core requirementMedically Necessary: service that is reasonable and required to identify, diagnose, treat, correct, cure, palliate, or prevent a disease, illness, injury, disability, or other medical condition

AppropriatenessAppropriate in terms of service, amount, scope, and duration based on generally-accepted standards of good medical practice

Location and purposeProvided in the most appropriate location and for medical reasons rather than for convenience or cosmetic reasons

Emergency applicationFor emergency services, necessity is determined using the prudent layperson standard

Field triage categories

Four-category field triage processInjury Patterns; Mental Status and Vital Signs; Mechanism of Injury Criteria; Emergency Medical Services Judgment

PurposeUsed to identify high and moderate risk for serious injury in civilian trauma systems (not mass casualty or in-hospital responses)

High/moderate risk useCriteria guide triage decisions, destination selection, and consideration of air medical services for time‑sensitive care