DraftUnitedHealthcarePolicy CS003PA.S

Ambulance Services (for Pennsylvania Only)

This policy governs medical necessity, coverage, definitions, codes, and prior authorization for ambulance services (ground and air) for UnitedHealthcare members in Pennsylvania. It affects providers submitting claims for ambulance transport and utilization reviewers determining coverage under Pennsylvania law.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for Pennsylvania Only)

Policy CodePolicy CS003PA.S

Change TypeCode addition & content updates

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure coding and prior authorization processes reflect addition of HCPCS A0140 for Ground/Other Ambulance claims.

SourceLink

POLICY UPDATE CHANGES

Added HCPCS code A0140 to Ground/Other Ambulance applicable codes.

Removed definition of 'Covered Health Care Service(s)'.

Updated Clinical Evidence and References sections to reflect the most current information.

Archived previous policy version CS003PA.R

multipleAmbulance HCPCS/CPT codes listed

0540-0549Ambulance revenue codes listed

PAPolicy applies to state

PA requiredNon-emergency air ambulance

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HCPCS code added in revision

Coverage Criteria for Ambulance Services

Emergency Air Ambulance - Medically Necessary

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

Emergency air ambulance medical necessity: 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 include: ground transport times excessive (30-60 minutes or longer); weather or traffic make ground ambulance transportation impractical, impossible, or overly time consuming; pickup point inaccessible by ground ambulance).see examples in text

Destination requirement: The member's destination is the nearest acute care hospital that can meet the member's needs.

Request or level-of-care during transport: One of the following must be present: Services requested by police or medical authorities at the site of an Emergency; OR advanced or basic life support is required during transportation.

Exclusion note: Emergency Air Ambulance services are not considered Medically Necessary for all other indications (i.e., when the listed criteria are not met).

Medical necessity for air/ground emergency transport

Covered when transport meets clinical necessity and aligns with field triage and position statements:

Primary medical necessity conditions: Transport (air or ground) is medically necessary when ALL of the following are true: (1) the patient requires initiation or continuation of advanced or specialty care not available locally OR requires expedited delivery to definitive care for a time-sensitive intervention OR requires extraction/evacuation from an inaccessible environment; (2) the mode of transport chosen is the least risky option that meets the clinical objective; (3) documentation supports field triage criteria or treating/receiving clinician certification of medical necessity.

Mode preference and dispatch: Ground emergency medical services (GEMS) are preferred when GEMS resources can meet critical care and timely transport needs; GEMS clinicians should be empowered to cancel air medical response if it would place air or ground crews at undue risk or would not align with the primary patient-centered goals.

Field triage alignment: Documentation should reference field triage criteria (high/moderate risk injury patterns, abnormal vital signs/mental status, mechanism of injury, or EMS judgment) when used to justify mode selection.

Evidence-informed situational criteria

Considerations where air transport may be associated with benefit (evidence-based):

Interfacility trauma transfers 21-90 miles: In one retrospective cohort (Stewart et al. 2021), helicopter transport (HT) for inter-facility trauma transfers from non-tertiary centers 21-90 miles from a tertiary trauma center was associated with decreased 72-hour mortality compared with ground transport.distance 21-90 miles

Study observational; patient severity and selection bias noted.

Interfacility stroke transfers >40 miles: A retrospective study of stroke transfers (Kunte et al. 2021) found air transport shortened interfacility travel time only when distances exceeded ~40 miles; transfer mode did not independently affect functional outcome when controlling for treatments and stroke severity.>40 miles

Logistics prior to EMS arrival and total transfer time influence benefit.

Systematic review evidence:

Air Ambulance transportation that does not meet the covered indications described in this policy is not eligible for coverage and may be denied. Refer to Pennsylvania Code, Title 55, Chapter 1245.54 for additional noncompensable services and items that may apply.

Scene helicopter emergency medical services (HEMS) overtriage is a recognized concern. Published reviews and single‑center chart reviews report that a substantial proportion of scene‑transported trauma patients are discharged within 24 hours post‑transport (for example, one retrospective review found 21.7% of HEMS scene patients discharged within 24 hours), suggesting some scene air transports may be resource‑driven rather than clinically necessary.

Systematic reviews of observational studies also highlight heterogeneity in outcomes and selection bias across HEMS studies, underscoring the need to apply field triage criteria and clinical judgment to limit air response to patients likely to benefit.

This Medical Policy is provided for informational purposes to assist interpretation of UnitedHealthcare standard benefit plans and does not constitute medical advice. Federal, state, or contractual benefit plan requirements govern in the event of a conflict; providers and reviewers must check those requirements before applying this policy.

Emergency Air Ambulance services are not considered Medically Necessary for indications other than those explicitly listed in the Emergency Air Ambulance criteria above. If the criteria are not fully met—such as when ground transport is practical and timely—air ambulance is not medically necessary.

HEMS is unlikely to benefit patients with minor injuries, normal vital signs, or when ground transport can provide timely definitive care. Evidence summaries and cohort data indicate limited outcome benefit and notable overtriage where ground transport would have been appropriate; therefore, air response should be reserved for situations meeting the policy’s emergency air ambulance criteria (e.g., excessive ground times, inaccessible pickup, or when ALS care during transport is required).

Coding — Ambulance Codes and Modifiers

Air AmbulanceHCPCS

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 AmbulanceHCPCS

A0140	Nonemergency transport and air travel (private or commercial) intra- or interstate
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

1–10 of 24

1/3

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

Ambulance ModifiersModifier

Ambulance Modifiers D,E,G,H,I,J,N,P,QL,R,S,X

Modifiers indicating origin and destination; QL used when patient pronounced dead after ambulance called; X only as destination in second position.

Ground/Other Ambulance applicable HCPCSHCPCS

A0140

Added Ground/Other Ambulance HCPCS code A0140

Ground/Other Ambulance applicable codesHCPCSCovered

A0140

Ground/Other Ambulance (added in revision history)

Excessive ground transport time threshold

Excessive ground transport time30-60 minutes or longer

Other examples of impractical ground transportWeather, traffic, or inaccessible pickup point making ground transport impractical or impossible

Policy implicationExcessive ground transport time is an explicit criterion supporting Emergency Air Ambulance medical necessity

Air faster than ground for interhospital transfers

Study finding (Kunte et al., 2021)Air transport shortened total interhospital transfer times only when traveling more than 40 miles

Provider Actions, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Authorization for Non‑Emergency Ground Ambulance

Certain UnitedHealthcare plans require prior authorization for non-emergency ground ambulance transports. Verify federal, state, and contractual requirements to determine whether prior authorization applies to the member's plan.

Applies to non-emergency ground ambulance transports.
Check member's contract and state/federal rules for exceptions.

Prior Authorization

Prior Authorization for Non‑Emergency Air Ambulance

Prior authorization is required for all non-emergency air ambulance transports. Do not schedule or bill for non‑emergency air transport without an approved prior authorization when the member's plan requires it.

Required for non-emergency air ambulance.
Ensure prior authorization aligns with updated policy effective 2025-11-01.

Background

Ambulance services—including ground, air, or water—are used when they are the only safe means to transport a member to the nearest facility due to the severity of illness or injury, and the mode of transport is determined by appropriate authorities. Emergency Air Ambulance is considered medically necessary when the member requires immediate transport that cannot be provided by ground and a delay may endanger life or health (examples include excessive ground transport times of 30–60 minutes or longer, impassable or unsafe ground conditions, or an inaccessible pickup point), when the destination is the nearest capable acute care hospital, and when services are requested by authorities at the scene or advanced/basic life support is required during transport.

Definitions

Air Ambulance — definition

DefinitionAir Ambulance: Medical transport by rotary wing (helicopter) or fixed wing aircraft certified as an 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 certified as a fixed wing Air Ambulance and such services and supplies as may be Medically Necessary

Emergency — definition for emergency condition

DefinitionEmergency: A medical condition with acute symptoms such that a prudent layperson could reasonably expect that lack of immediate attention would result in serious jeopardy, serious impairment of bodily functions, or serious dysfunction of any bodily organ or part

Standard referenced

Revision History and Policy Updates

2025-11-01code additionLatest

Added HCPCS code A0140 to Ground/Other Ambulance applicable codes.

2025-11-01definition removal

Removed definition of 'Covered Health Care Service(s)'.

2025-11-01supporting information update

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for Pennsylvania Only)

Policy CodePolicy CS003PA.S

Change TypeCode addition & content updates

Effective DateNov 1, 2025

Next Review Date

Key ActionEnsure coding and prior authorization processes reflect addition of HCPCS A0140 for Ground/Other Ambulance claims.

SourceLink

On This Page

A Cochrane systematic review (Galvagno et al. 2015) of non-randomized trials found heterogeneous results; some inter-facility transfer studies suggested small-to-moderate benefit of HEMS but overall evidence quality was low and inconclusive.

Evidence limited by nonrandomized designs and selection bias.

Study scopeRetrospective review of 205 patient transfers to a single comprehensive stroke center

Limitations notedAuthors cited retrospective design, small sample size, and selection of patients who received tPA and/or thrombectomy

Air transfer distance benefit threshold

Distance threshold for air benefit>40 miles — air transfers were faster only when interfacility transfer distance exceeded 40 miles

Contextual evidenceOne trauma study reported HEMS associated with decreased 72-hour mortality for transfers 21–90 miles from a tertiary center

InterpretationDistance-based benefits are evidence-informed considerations, not prescriptive criteria

Note

Appropriate Use and Mode Selection Preference

Reserve air medical transport only when one or more of the following patient‑centered goals are met: initiation/continuation of advanced or specialty care not available locally, expedited delivery to definitive time‑sensitive care, or extraction/rescue from inaccessible environments. Ground EMS (GEMS) is preferred when it can meet critical care and timely transport needs.

Air transport appropriate when it enables advanced/specialty care not available locally.
Use air transport for expedited time‑sensitive definitive care when ground cannot meet time requirements.
Prefer GEMS when clinical needs and timeliness can be met by ground resources.

Denial Risk

Air Ambulance Not Meeting Criteria — Coverage Exclusion

Air ambulance transports that do not meet the covered indications in the Air Ambulance criteria are not eligible for coverage. Review clinical criteria and regional guidance; denials may result when criteria are not met.

Services not meeting Air Ambulance criteria are non‑covered.
Confirm clinical indications and documentation prior to transport to avoid denial risk.

Documentation Required

Ambulance Modifier Documentation

Providers must document ambulance origin and destination using the appropriate ambulance modifiers (first modifier = origin, second modifier = destination). Modifier X may only be used as a destination (second position).

Use two modifiers on ambulance claims: first = origin, second = destination.
Modifier X = intermediate physician's office stop (destination only).
QL is used when patient pronounced dead after ambulance called (applies in lieu of origin/destination).

Documentation Required

Certificate of Medical Necessity and On‑Scene Certification

For scene air transports, the transport program medical director or a receiving physician may complete the Certificate of Medical Necessity when consistent with regional policy and best medical judgment.

AMPA supports receiving physician or transport program medical director certifying on‑scene transports.
Follow regional policy and document who certified medical necessity.

Note

Check Governing Contractual, State, and Federal Requirements

Before applying this policy, check applicable federal, state, and contractual requirements. In the event of conflict between this policy and governing rules, the federal/state/contractual requirements govern coverage.

Federal, state, or contractual requirements take precedence over this policy.
Verify plan‑specific rules prior to authorization and transport.

Prudent layperson standard used to define emergency severity

Scope noteCheck federal, state, or contractual definitions that may supersede this definition

Medically Necessary — definition describing compensable and necessary services

DefinitionMedically Necessary: A service/item/procedure that is compensable under the MA Program, necessary for treatment or management of illness, injury, or disability, prescribed by an appropriate licensed practitioner, and consistent with generally accepted standards of medical practice

Functional criteriaIncludes services expected to prevent, reduce, or ameliorate effects of illness/injury and assist the recipient to achieve or maintain maximum functional capacity

Standards of evidenceBased on credible scientific evidence from peer-reviewed literature or, if unavailable, physician specialty society recommendations or expert opinion

High and Moderate Risk field triage criteria

Field triage categoriesHigh and Moderate Risk criteria include: injury patterns, mental status and vital signs, mechanism of injury, and EMS judgment

Examples — Injury patternsPenetrating injuries to head/neck/torso/proximal extremities; suspected spinal injury with new motor/sensory loss; suspected pelvic fracture; amputation proximal to wrist or ankle

Examples — Vitals/mental statusUnable to follow commands (motor GCS < 6); respiratory rate <10 or >29; respiratory distress; room air SpO2 <90; age-specific hypotension criteria

Mechanism and EMS judgmentHigh-risk mechanisms (e.g., high-risk auto crash, need for extrication) and clinician/EMS judgment are included in criteria

Covered Health Care Service(s) — definition removed from policy

Status of definitionThe definition of 'Covered Health Care Service(s)' has been removed from the policy in the 11/01/2025 revision

Revision noteChange recorded in Policy History/Revision Information: definition removed

Operational impactProviders should reference remaining definitions and applicable contractual/state/federal definitions as this term is no longer defined in the policy

Updated Clinical Evidence and References sections to reflect the most current information and archived previous policy version CS003PA.R.