(Medicare Benefit Policy Manual)

10.3.4  Transports to and from Medical Services for Beneficiaries who are not Inpatients (Rev. 14, 05- 28-04) A3-3114.C.3, HO -236.3.C, AB -00-127, B3- 2120.3C   Ambulance transports to and from a covered destination (i.e., two 1- way trips) furnished to a benef iciary who is not an inpatient of a provider for the purpose of obtaining covered medical services are covered, if all program requirements for coverage are met.   In addition, coverage of ambulance transports to and from a destination under these circumsta nces is limited to those cases where the transportation of the patient is less costly than bringing the service to the patient.  For frequent transports of this kind subject to the A/B MAC (A)s or (B)s discretion, additional information may be required supporting the need for ambulance services relative to the option of admission to a treatment facility.   Specialized services are covered services that are not available at the facility in which the beneficiary is a patient.   10.3.5 - Locality (Rev. 236, Issued: 06 -16-17, Effective: 09- 18-17, Implementation: 09- 18-17)  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.   EXAMPLE:  Mr. A becomes ill at home and requires ambulance service to the hospital.  The small community in which he lives has a 35 -bed hospital.  Two larg e metropolitan hospitals are located some distance from Mr. A's community and both regularly provide hospital services to the community's residents.  The community is within the "locality" of both metropolitan hospitals and direct ambulance service to either of these (as well as to the local community hospital) is covered.   10.3.6 - Appropriate Facilities  (Rev. 1, 10- 01-03) A3-3114.C.6, HO -236.3.F   The term appropriate facilities means that the institution is generally equipped to provide the needed hospi tal 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.  For example, the nearest tuberculosis hospital  may be in another State and that States 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.   EXAMPLE:  Mr. A becomes ill at home and requires ambulance service to the hospital.  The hospitals servicing the community in which he lives are capable of providing general hospital care.  However, Mr. A requires immediate kidney dialysis, and the needed equipment is not available in any of these hospitals.  The service area of the nearest hospit al having dialysis equipment does not encompass the patients home.  Nevertheless, in this case, ambulance service beyond the locality to the hospital with the equipment is covered since it is the nearest one with appropriate facilities.   10.3.7 - Partial Payment  (Rev. 1, 10- 01-03) A3-3114.C.4, HO -236.3.D   Where ambulance service exceeds the limits defined in 10.3 through 10.3.7, above, refer to 20, item #5  for instructions on partial payment.  10.3.8 - Ambulance Service to P hysicians Office  (Rev. 1, 10- 01-03) A3-3114.C.7, HO -236.3.G, B3- 2130.3.G   These trips are covered only under the following circumstances:    The ambulance transport is enroute to a Medicare covered destination as described in 10.3 ; and    During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination.   In such cases, the patient will be deemed to have been transported directly to a covered destination and payment may be made for a single transport and the entire mileage of the transport, including any additional mileage traveled because of the stop at the physicians office.   10.3.9 - Transportation Requested by Home Health Agency  (Rev. 1, 10- 01-03) A3-3114.C.8, HO -236.3.H, B3- 2130.3.H   Where a home health agency has a beneficiary transported by ambulance to a hospital or skilled nursing facility to obtain needed medical services not other wise available to the individual, the trip is covered as a Part B service only if the requirements are met for ambulance transportation from wherever the patient is located (place of origin).  Such transportation is not covered as a home health service.   10.3.10 - Multiple Patient Ambulance Transport  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Effective April 1, 2002, if two patients are transported to the same destination simultaneously, for each Medicare benef iciary, Medicare will allow 75 percent of the payment allowance for the base rate applicable to the level of care furnished to that beneficiary plus 50 percent of the total mileage payment allowance for the entire trip.   If three or more patients are trans ported to the same destination simultaneously, then the payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of the base rate applicable to the level of care furnished to the beneficiary.  However, a single payment allowa nce for mileage will be prorated by the number of patients onboard.  This policy applies to both ground and air transports.  10.4 - Air Ambulance Services  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered.  However, A/B MACs (A) and (B) approve claims only if the beneficiarys medical condition is such that transportation by either basic or  advanced life support ground ambulance is not appropriate.   There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft.  The higher operational costs of the two types of aircraft are recognized with two  distinct payment amounts for air ambulance mileage.  The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown and is expressed in statute miles (not nautical miles).   1. Fixed Wing Air Ambulance (FW)   Fixed wing air ambulance is furnished when the beneficiarys medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.  Generally, transport by fixed wing air ambulance may be necessary because the beneficiarys condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility.  Transport by fixed wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.   2. Rotary Wing Air Ambulance (RW)   Rotary wing air ambulance is furnished when the beneficiarys medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate.  Generally, transport by rotary wing air ambulance may be necessary because the beneficiarys condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid deli very to the nearest appropriate facility.  Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.   10.4.1 - Coverage Requirements  (Rev. 1, 10- 01-03) A3-3114.C.11.A, B3- 2120.4A   Air ambulance transportation services, either by means of a helicopter or fixed wing aircraft, may be determined to be covered only if:    The vehicle and crew requirements described in 10.1  are met;    The beneficiar ys medical condition required immediate and rapid ambulance transportation that could not have been provided by ground ambulance; and either   1. The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or   2. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities as described in 10.4.4 .  Additionally, Medicare allows payment for an air ambulance service when the air ambulance takes off to pick up a Medicare beneficiary, but the beneficiary is pronounced dead before being loaded onto the ambulance for transport (either before or a fter the ambulance arrives on the scene).  This is provided the air ambulance service would otherwise have been medically necessary.  In such a circumstance, the allowed amount is the appropriate air base rate, i.e., fixed wing or rotary wing.  However, no amount shall be allowed for mileage or for a rural adjustment that would have been allowed had the transport of a living beneficiary or of a beneficiary not yet pronounced dead been completed.   For the purpose of this policy, a pronouncement of death is e ffective only when made by an individual authorized under State law to make such pronouncements.  This policy also states no amount shall be allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to a bort the flight.  Further, no amount shall be allowed if the aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but not actually taken off.   10.4.2 - Medical Reasonableness  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Medical reasonableness is only established when the beneficiarys condition is such that the time needed to transport a beneficiary by ground, or the instability of transportation by ground, poses  a threat to the beneficiarys survival or seriously endangers the beneficiarys health.  Following is an advisory list of examples of cases for which air ambulance could be justified.  The list is not inclusive of all situations that justify air transport ation, nor is it intended to justify air transportation in all locales in the circumstances listed.    Intracranial bleeding -  requiring neurosurgical intervention;   Cardiogenic shock;   Burns requiring treatment in a burn center;   Conditions requiring treatment  in a Hyperbaric Oxygen Unit;   Multiple severe injuries; or   Life-threatening trauma.   10.4.3 - Time Needed for Ground Transport  (Rev. 1, 10- 01-03) A3-3114.C.11.C, B3- 2120.4.C   Differing Statewide Emergency Medical Services (EMS) systems determine the amount  and level of basic and advanced life support ground transportation available.  However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the beneficiarys life or health.  As a general guideline, when it would take a ground ambulance 30 -60 minutes or more to transport a beneficiary whose medical condition at the time of pick -up required immediate and rapid transport due to the nature and/or severity of the beneficiarys illness/injury, A/B MACs (A) and (B) should consider air transportation to be appropriate.   10.4.4 - Hospital to Hospital Transport  (Rev. 1, 10- 01-03) A3-3114.C.11.E, B3- 2120.4.E