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 Medicare pays for air ambulance services only if the enrollees medical condition is such that 
transportation by either basic, the provision of medically necessary supplies and services or advanced life 
support, an emergency medical technician (EMT) intermediate or EMT-Paramedic ground ambulance is not 
appropriate. Air ambulance services may be covered only if: 
 
1. certain vehicle and crew requirements are met; 
 
2. the enrollees medical condition needed immediate and rapid ambulance transport that could not have been 
provided by ground ambulance; and  
 
3. either the point of pickup is not accessible by ground vehicle or great distances or other obstacles are 
involved in getting the patient to the nearest hospital with appropriate facilities. 
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10.4, and 10.4.1, and 30.1.1. 
 
The rules say that an ambulance transport is covered to the nearest appropriate facility to obtain necessary 
diagnostic and/or therapeutic services. 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 
Medicare Administrative Contractors (MACs) have the discretion to define locality in their service areas. 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 patient's condition. 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 beneficiary's condition requires a higher level of trauma care or other specialized 
service available only at the more distant hospital. An institution is also not considered an appropriate facility if 
there is no bed available. The contractor, however, will presume that there are beds available at the local 
institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time 
the ambulance service was provided. You can find this information in the Centers for Medicare and Medicaid 
Service, Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 10, Section 10.3, 
10.3.5, 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.