Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for the ambulance services (A0431 and A0436) provided on November 12, 
2022. 
 
You asked the Plan to pay for the ambulance services. You say that the enrollee was transported to the nearest 
hospital. The Plan denied your request. The Plan says that the Plan says the enrollee was not transported to the 
nearest facility. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 the ambulance services. Our physician 
reviewer found the documentation supports that the enrollee suffered from an illness or injury that 
contraindicates transportation by any means other than ambulance. The documentation supports that the 
enrollee's condition was such that the time needed to transport an enrollee by ground, or the instability of 
transportation by ground, posed a threat to the enrollee's survival or seriously endangered the enrollee's health. 
The documentation supports that the transferring hospital did not have adequate facilities to provide the 
medical services needed by the enrollee. The provided records do not support that the services could have been 
provided at a closer facility.  
 
The Medicare rules say that only local transportation by ambulance is covered, and therefore, only mileage to 
the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that 
meet the destination requirements can treat the patient appropriately and the locality of each facility 
encompasses the place where the ambulance transportation of the patient began, then the full mileage to any 
one of the facilities to which the beneficiary is taken is covered. The term "locality" with respect to ambulance 
service means the service area surrounding the institution to which individuals normally travel or are expected 
to travel to receive hospital or skilled nursing services. The MACs have the discretion to define locality in their 
service areas. Our physician reviewer found that it appears that the locality of each facility encompasses the 
place where the ambulance transportation of the enrollee began, and therefore, the full mileage to any one of 
the facilities to which the beneficiary is taken is covered. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services have been met. Therefore, we decided that the Plan has 
to pay for the ambulance services (A0431 and A0436) provided on November 12, 2022.  
 
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.