Emergency Air/Water Ambulance Services Medical Guideline
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This guideline governs medical necessity and documentation for emergency transportation of ill or injured members by air or water ambulance. Coverage varies by benefit plan and is subject to the member's plan terms, applicable laws, and state mandates.
No material clinical or coverage changes in this revision.
Emergency Air and Water Ambulance Coverage
Emergency Air/Water Ambulance Medical Necessity
Emergency air/water ambulance services are medically necessary only when <strong>all</strong> of the following criteria are met, and at least one transport-necessity condition applies.
ALL of the following
- The member has a critical or unstable emergency requiring immediate transport.
- The transferring hospital, facility, or locale does not have adequate facilities to provide the medical services needed by the member.
- The member is transferred to the closest acute care facility at which the required medical care can be provided.
AND at least ONE of the following
- The time to transport by ground would be significantly greater than the time to transport by air, including preparation and mobilization time required by the air ambulance team, and the member's condition could be jeopardized by the delay.
- Ground ambulance transport is not feasible, such as because of a remote location or extreme weather or traffic conditions.
- The member requires capabilities or specialty services during transport that can be provided by the air/water transport team but not by ground transport.
Review the member's contract and endorsements for applicable exclusions, prior authorization requirements, and other benefit requirements. Ambulance services used for convenience or personal preference are not medically necessary and are not a covered benefit. Transport back to the continental United States (repatriation), or transport to a facility preferred by the member or family when a geographically closer facility can provide the needed services, is not a covered benefit and/or is not medically necessary.
Mileage for air ambulance service is medically necessary only up to the distance required to transport the member from the trip origin to the nearest appropriate facility. Mileage in excess of that distance is not medically necessary.
Transport beyond the nearest facility equipped to provide the most appropriate care for the member's condition, as determined by WPS Health Insurance, is not medically necessary.
If the service is used for a condition or diagnosis other than one listed in the Indications of Coverage, it is considered experimental, investigational, and unproven to affect health outcomes. If the condition or diagnosis is listed in the Indications of Coverage but the applicable guideline criteria are not met, the service is considered not medically necessary.
Non-covered or not medically necessary situations include convenience or personal-preference transport, repatriation to the continental United States, transport to a preferred facility when a closer appropriate facility is available, mileage beyond the nearest appropriate facility, and transport beyond the nearest facility equipped to provide the most appropriate care. Services for diagnoses outside the Indications of Coverage are considered experimental, investigational, and unproven; services for listed diagnoses that do not meet the coverage criteria are not medically necessary.
Documentation and Coverage Considerations
Order and Transport Rationale
Obtain a Standard Written Order (SWO) prescribed by a qualified healthcare provider that identifies the member’s diagnosis and explains the medical reason for air or water ambulance transport. Include the ordering physician’s name and phone number when the request is made to the air ambulance provider, as well as any additional equipment or personnel required.
- Written order concerning the member’s diagnosis.
- Qualified healthcare provider involvement and ordering physician contact information.
- Rationale for air ambulance transport and any additional equipment or personnel needed.
Clinical Records Supporting Medical Necessity
Submit medical records sufficient to establish medical necessity and, when applicable, the member’s continued need for or use of the service. The record should describe the member’s diagnosis, chief complaint, current condition, and relevant clinical course.
- Diagnosis and chief complaint.
- Current clinical summary, including comorbidities and functional limitations.
- Inpatient stay and progress, when applicable.
- Medical necessity and continued need or use, when applicable.
Origin, Destination, and Mileage
Document the complete transport route and one-way mileage. Identify both the originating and receiving facilities with the applicable contact name and telephone number, and report air and land mileage separately when applicable.
- Origin facility name and contact name/phone number.
- Destination facility name and contact name/phone number.
- One-way transport mileage, including air mileage and land mileage.
Coding and Current Clinical Support
Use the correct coding for the item or service and ensure that the claim meets all applicable coding guidelines. Support air or water ambulance services with the most current medical references and specialty-society guidance, such as MCG or NCCN, and provide current medical records supporting medical necessity.
- Apply correct coding for the billed item or service.
- Use the most current medical references and specialty-society guidelines.
- Provide current clinical records supporting the medical necessity of air or water ambulance transport.
Convenience, Preference, and Repatriation Transport
Do not arrange or bill ambulance transport solely for convenience or personal preference. Repatriation to the continental United States, or transport to a member- or family-preferred facility when a geographically closer facility can provide the needed services, is not a covered benefit and/or is not medically necessary.
- Convenience or personal-preference transport is not medically necessary and is not covered.
- Repatriation transport to the continental United States is not covered.
- Transport to a preferred facility is not covered when a geographically closer facility can provide the needed services.
Excess Mileage or Destination Distance
Limit the transport route and mileage to the nearest appropriate facility, or to the nearest facility equipped to provide the most appropriate care for the member’s condition, as determined by WPS. Excess mileage and transport beyond that facility are not medically necessary.
- Mileage beyond the distance from the trip origin to the nearest appropriate facility is not medically necessary.
- Transport beyond the nearest facility equipped to provide the most appropriate care is not medically necessary.
- Document the clinical basis for selecting the destination facility.
Unlisted Diagnosis or Unmet Criteria
Confirm that the member’s condition or diagnosis falls within the guideline’s indications and that all applicable criteria are met before arranging transport. A condition outside the listed indications is considered experimental, investigational, and unproven; a listed condition that does not meet the criteria is not medically necessary.
- Diagnosis outside the Indications of Coverage: experimental, investigational, and unproven.
- Listed diagnosis but unmet criteria: not medically necessary.
- Services deemed experimental, investigational, and/or unproven are not covered under the clinical guidelines.
Plan and Legal Limitations
Verify the member’s specific benefit plan before providing services. Review the contract and endorsements for exclusions, prior authorization or other benefit requirements, and apply all applicable plan terms, state mandates, laws, benchmark requirements, and federal law; state mandates, laws, or benchmarks supersede this guideline.
- Coverage may vary by member benefit plan; this guideline does not itself authorize services or guarantee payment.
- Review contracts and endorsements for exclusions, prior authorization, and benefit requirements.
- Coverage is subject to the applicable plan’s terms, exclusions, and limitations.
- Apply applicable state mandates, laws, benchmarks, and federal law; state mandates, laws, or benchmarks supersede this guideline.
- Confirm benefit and network status with customer service using the member’s identification card when needed.
Policy Scope and Service Context
This guideline addresses emergency transportation of ill or injured patients by air or water ambulance. Air ambulance services may be provided by rotary-wing helicopters or fixed-wing airplanes. Air/water transport is intended for critical or unstable emergencies when the current location cannot provide the required care and rapid transport, access limitations, or specialized transport capabilities make ground transport inadequate.
Transportation Terms
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