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 enrollee's 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 enrollee's 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 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. 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 beneficiary's 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 patient's admission would permit a finding that the institution did not have
"appropriate facilities." For example, the nearest tuberculosis hospital may be in another State and that
State's law precludes admission of nonresidents. An institution is also not considered an appropriate facility if
there is no bed available. The A/B MAC (A) or (B), 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 rule in the Medicare Benefit Policy
Manual Chapter 10, Ambulance Services 10.3.6, Appropriate Facilities (Rev. 1, 10-01-03) A3-3114. C.6, HO-
236.3.F.
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. The Plan
contract says that non-emergency ambulance transport requires prior authorization. You can see this on page 65
of the Plans 2021 Evidence of Coverage.