Appeal type: Transportation
Decision: Partially Favorable

 
We decided that the Plan has to pay for an ambulance service on February 16, 2023. We decided that the Plan 
does not have to pay for an ambulance service on February 17, 2023.  
 
You asked the Plan to pay for an ambulance service, advanced life support, emergency transport, level 1 
(A0427) and ground mileage (A0425) provided on February 16, 2023, and February 17, 2023. You say that you 
had to go to the hospital twice due to really bad teeth. You also say you have multiple sclerosis, in the last 
stages, and stopped taking the medication for it because the medication was no longer helping. The Plan says 
that an ambulance transport must be deemed emergent and medically necessary. 
 
Medicare pays for ambulance services only when an emergency exists or when other means of transport would 
endanger the patients health. The Plan follows the same rules. 
 
We decided that the Plan has to pay for an ambulance service on February 16, 2023.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an ambulance service on February 16, 2023, 
and February 17, 2023. Our reviewer says that the service is partially medically necessary. Our physician 
reviewer found that the transportation provided via ambulance to the emergency department on February 16, 
2023, was medically necessary and reasonable. You required the expertise of trained personnel or the 
equipment available only on an ambulance in order to effectuate a safe transport. Transportation could not have 
been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering your 
condition. A prudent layperson would believe that immediate medical attention was required for someone with 
severe hypertension. Therefore, we decided that the Plan has to pay for an ambulance service on February 16, 
2023.  
 
We also decided that the Plan does not have to pay for an ambulance service on February 17, 2023. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for an ambulance service on February 16, 2023, 
and February 17, 2023. Our reviewer says that the service is partially medically necessary. Our physician 
reviewer found that the transportation provided via ambulance to the emergency department on February 17, 
2023, was not medically necessary. You did not require the expertise of trained personnel or the equipment 
available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided 
by other means (stretcher van, wheelchair van, private car, taxi) without endangering your condition. A prudent 
layperson would not believe that immediate medical attention was required for someone with chronic dental 
pain. Therefore, we decided that the Plan does not have to pay for an ambulance service on February 17, 2023. 
 
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.