Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to hold you harmless for the ambulance services provided on April 17, 2021.
You asked the Plan to hold you harmless for the ambulance services. You say that an ambulance was called for you on April 17, 2021, because you felt you were having a heart attack. Care was provided on scene, and the paramedics told you that you were fine and did not need to go to the hospital. You accepted their recommendation as medical professionals and did not go to the hospital, but then had to call another ambulance for transport less than an hour later when symptoms returned. You feel this bill is unfair as you only took the advice of professionals and did not know this care would not be covered. The Plan denied your request. The Plan says that the ambulance benefit is a transportation benefit. When no transportation is provided, there is no payable service. Therefore, payment is denied.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the record shows that the billed code for the service in question is A0427. CPT Code Manual definition of code A0427 is ambulance service, advanced life support, emergency transport, level one.
We find that there is a discrepancy between the billed services and the narrative for care. Specifically, the Plan denied the services at issue as no transportation provided, but the service was billed with a transportation code. Ambulance treatment and response without transport is billed with a difference CPT code.
In addition, documentation for the ambulance services at issue were not provided. The records included appear
to detail information for the second ambulance which arrived that same day and did provide transportation to
the hospital. The narrative in these records references that there was an ambulance there earlier in the evening
and that transportation was refused at that time. There is also no signed documentation from the first
ambulance services that indicate that the enrollee willingly refused transportation and was notified of the risks.
We find that CPT code A0427 is not supported in the medical record. Specifically, it appears based on the
record that the service at issue is ambulance response and treatment without transport. Insufficient
documentation was provided. Ambulance services without transportation are not a Medicare-covered service;
however, based on an apparent billing issue and lack of documentation to support that this service is not
covered by Medicare, we decided that you cannot be held responsible for this bill as it is submitted. Therefore,
we decided that the Plan has to hold you harmless for the ambulance services provided on April 17, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter