Appeal type: unknown
Decision: unknown

 
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 patients 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 Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-16, 
Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2. 
 
The rules state 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. Because all duly licensed hospitals and skilled nursing facilities 
(SNFs) are presumed to be appropriate sources of health care, only in exceptional situations where the 
ambulance transportation originates beyond the locality of the institution to which the beneficiary was 
transported, may full payment for mileage be considered. And then, only if the evidence clearly establishes that 
the destination institution was the nearest one with appropriate facilities under the particular circumstances. 
 
The term appropriate facilities means that the institution is generally equipped to provide the needed hospital 
or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician 
or a physician specialist is available to provide the necessary care required to treat the patients condition. 
However, the fact that a particular physician does or does not have staff privileges in a hospital is not a 
consideration in determining whether the hospital has appropriate facilities. Thus, ambulance service to a more 
distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not 
make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities. The 
fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient 
does not warrant a finding that a closer institution does not have appropriate facilities. Such a finding is 
warranted, however, if the beneficiarys condition requires a higher level of trauma care or other specialized 
service available only at the more distant hospital. In addition, a legal impediment barring a patients admission 
would permit a finding that the institution did not have appropriate facilities. You can find these rules in 
Medicare Benefit Policy Manual Chapter 10, Sections 10.3 and 10.3.6.  
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.