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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that plans must pay for ambulance services when an emergency exists or when other means of 
transport would endanger the patient's health. An emergency is defined as when a prudent layperson would 
believe that without immediate medical attention there would be serious jeopardy to his or her health. You can 
find these rules in the Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2. 
 
The rules say that Non-emergency ambulance services may be those that are scheduled in advance scheduled 
services being either repetitive or non-repetitive. 
 
Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 for full details 
regarding non-emergency ambulance services. 
 
One condition of coverage is that the beneficiary be bed-confined. Please refer to CMS IOM Publication 100-
02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.3 for additional information on bed-
confinement. 
 
Statements about the patient?s bed-confined status must be validated in the record with contemporaneous 
objective observations and findings as to the patient?s functional physical or mental limitations that have 
rendered him bed-bound. 
 
Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as 
reasonable and necessary as indicated in CMS IOM Publication 100-04, Medicare Claims Processing Manual, 
Chapter 6, Section 20.3.1. 
 
Refer to CMS IOM Publications 100-04, Medicare Claims Processing Manual, Chapter 15, Section 10.4 and 
100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3.3 for information on ambulance transport 
for a beneficiary who is a SNF resident in a stay not covered by Part A.  
 
Appropriate Facilities 
 
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3.6 outlines coverage 
for ambulance transports to appropriate facilities. 
 
Special Note Regarding Patients Transported To and From Hemodialysis Centers: 
 
Only a fraction (approximately 10 percent) of End Stage Renal Disease (ESRD) patients on chronic 
hemodialysis requires ambulance transportation to and from hemodialysis sessions. The presence of ESRD and 
the requirement for hemodialysis do not alone qualify a patient for ambulance transportation. Medicare 
payment requires patients transported to and from hemodialysis centers to have other conditions such as those 
described in the tables below and requires adequate documentation of those conditions in the ambulance 
supplier?s trip/run sheet and in the medical records of other providers involved with the patient?s care. 
 
Physician Certification Statement (PCS) 
 
For scheduled and non-scheduled non-emergency ambulance transports, providers of ambulance transportation 
must obtain a written statement (PCS) from the patient?s attending physician certifying that medical necessity 
requirements for ambulance transportation are met. Refer to CFR, Title 42, Chapter IV, Subchapter B, Part 
410, Subpart B, Section 410.40 for full details regarding PCS requirements. 
 
Tables of Medical Conditions 
 
Medicare has established a list of medical conditions to assist with communicating patient?s conditions to the 
Medicare Administrative Contractors (MACs). Though not all-inclusive, the lists contain medical conditions 
for which ambulance transportation is commonly required and can be used to judge relative severity of 
conditions not listed. Please refer to the CMS IOM 100-04 Publication, Medicare Claims Processing Manual, 
Chapter 15, Section 40 for more information and for the link to the medical conditions. 
 
Medicare requires the trip/run sheet to include a description of the patient?s symptoms and physical findings in 
sufficient detail as to demonstrate conditions such as those described in the lists. 
 
Special Considerations Regarding Beneficiary Death 
 
Please see CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.2.6 for 
information on ambulance services and the death of a beneficiary. 
 
Limitations 
 
Medicare does not cover the following services: 
 
    Transportation via Mobile Intensive Care Unit (MICU) (if billed under Medicare Part A). 
    Parking fees. 
    Tolls for bridges, tunnels and highways. 
    Medicare does not provide payment for ?Ambulance response and treatment, no transport.? 
 
Non-emergency ambulance transportation is not covered for patients who are restricted to bed rest by a 
physician?s instructions but who do not meet the criteria as outlined in the manuals. 
 
Per regulation, ambulance services are not based only on the diagnosis. In addition to the diagnosis meeting 
medical necessity the requirement that any other means of transportation is contraindicated must also be met. 
Therefore, in order to support medical necessity, all ambulance transports require dual diagnosis codes. Billing 
and Coding: Ambulance Services (Ground Ambulance), A54574 provides a list of suggested primary diagnosis 
codes as well as the required dual diagnosis codes. Please refer to the billing and coding article for proper 
billing and coding instructions. 
 
Non-emergency ambulance transportation is not covered if transportation is provided for the patient who is 
transported to receive a service that could have been safely and effectively provided in the point of origin 
(residence, Skilled Nursing Facility [SNF], hospital, etc.). Such transportation is not covered even if the patient 
could only have gone for the service by ambulance. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Ambulance Services 
(Ground Ambulance) (L35162). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.