evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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)
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
10.4.4 - Hospital to Hospital Transport  (Rev. 1, 10- 01-03) A3-3114.C.11.E, B3- 2120.4.E   Air ambulance transport is covered for transfer  of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiarys health and the transferring hospital does not have adequate facilities to provide the m edical services needed by the patient.  Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care.  A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities.  Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patients family prefer a specific hospital or physician.   10.4.5 - Special Coverage Rule  (Rev. 1, 10- 01-03) A3-3114.C.11.F, B3- 2120.4.F   Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physicians office, or a beneficiarys home.   10.4.6 - Special Payment Limitations  (Rev. 133, Issued: 10- 22-10, Effective: 01- 01-11, Implementation: 01- 03-11)  If a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport.   If the air transport was medically appropriate (that is, ground transportation was contraindicat ed, and the beneficiary required air transport to a hospital), but the beneficiary could have been treated at a hospital nearer than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.  10.4.7 - Documentation  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)
(Medicare Benefit Policy Manual)
10.4.7 - Documentation  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  In order to determine the medical appropriateness of air ambulance services the A/B MAC (A) or (B) may request that documentation be submitted that indicates the air ambulance services are reasonable and necessary to treat the beneficiarys life-threatening condition. The contractors medical staff may consider reviewing all claims for air ambulance service s.  10.4.8 - Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilots Control  (Rev. 1, 10- 01-03)  The chart below shows the Medicare payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilots control.  Air Ambulance Scenarios:  Aborted Flights  Aborted Flight Scenario  Medicare Payment Determination  Any time before the beneficiary is loaded onboard (i.e., prior to or after take -off to  point -of-pickup.)  None.  Transport after the beneficiary is loaded onboard.  Appropriate air base rate, mileage, and rural adjustment.   10.4.9 - Effect of Beneficiary Death on Program Payment for Air Ambulance Transports  (Rev. 103; Issued:  02- 20-09; Effe ctive Date:  01 -05-09; Implementation Date:  03 -20-09)  Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare -covered service.  In general, if the beneficiary dies before being transported, then no Medicare payment may be made.  Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual  authorized by the State to make such pronouncements.   The chart below shows the Medicare payment determination for various air ambulance scenarios in which the beneficiary dies.  In each case, the assumption is that the ambulance transport would have othe rwise been medically necessary. If the flight is aborted for other reasons, such as bad weather, the Medicare payment determination is based on whether the beneficiary was onboard the air ambulance.
(Medicare Benefit Policy Manual)
Air Ambulance Scenarios:  Beneficiary Death  Time of Death Pronouncement  Medicare Payment Determination  Prior to takeoff to point -of-pickup with notice to dispatcher and time to abort the flight. None. NOTE:  This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off.) After takeoff to point -of-pickup, but before the beneficiary is loaded.  Appropriate air base rate with no mileage or rural adjustment; use the QL modifier when submitting the claim.  After the beneficiary is loaded onboard, but prior to or upon arrival at the receiving facility.  As if the beneficiary had not died.  10.5 - Joint Responses (Rev. 125, Issued 05- 14-10, Effective: 01- 04-10, Implementation: 06- 15-10)  A. BLS/ALS Joint Responses   In situations where a BLS entity provides the transport of the beneficiary and an ALS entity provides a service that meets the fee schedule definition of an ALS intervention (e.g., ALS assessment, Paramedic Intercept services, etc.), the BLS supplier may bill  Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists prior to submitting the Medicare claim.  Providers/suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) as determin ed by  their A/B MAC (A) or (B) upon request.   A/B MACs (A) and (B) must refer any issues that cannot be resolved to the regional office.   Medicare does not regulate the compensation between the BLS entity and the ALS entity.  If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be made.  In this situation, the ALS entitys services are not covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are beyond the scope of the BLS level of payment.  B. Ground to Air Ambulance Transports   When a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer to the air ambulance.
(Medicare Benefit Policy Manual)
When a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer to the air ambulance.  20 - Coverage Guidelines for Ambulance Service Claims  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)   Payment may be made for expenses incurred by a patient for ambulance service provided conditions l, 2, and 3 in the left-hand column have been met.  The right-hand column indicates the documentation needed to establish that the condition has been met.  Cond itions  Review Action  1. Patient was transported by an approved supplier of ambulance services.  1. Ambulance suppliers are explained in greater detail in 10.1.3
(Medicare Benefit Policy Manual)
2. The patient was suffering from an illness or injury, which contraindicated transportation by other means. ( 10.2) 2. (a) The A/B MAC (A) or (B) presumes the requirement was met if the submitted documentation indicates that the patient:   Was transported in an emergency situatio n, e.g., as a result of an accident, injury or acute illness, or  Needed to be restrained to prevent injury to the beneficiary or others; or  Was unconscious or in shock; or  Required oxygen or other emergency treatment during transport to the nearest appropr iate facility; or  Exhibits signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain; or  Exhibits signs and symptoms that indicate the possibility of acute stroke; or  Had to remain immobile because of a fracture that had not been set or the possibility of a fracture; or  Was experiencing severe hemorrhage; or   Could be moved only by stretcher; or  Was bed -confined before and after the ambulance trip. (b) Cond itions  Review Action  In the absence of any of the conditions listed in (a) above additional documentation should be obtained to establish medical need where the evidence indicates the existence of the circumstances listed below: (i) Patients condition would not ordinarily require movement by stretcher, or  (ii) The individual was  not admitted as a hospital inpatient (except in accident cases), or  (iii) The ambulance was used solely because other means of transportation were unavailable, or  (iv) The individual merely needed assistance in getting from his room or home to a vehicle.  (c)  Where the information indicates a situation not listed in 2(a) or 2(b) above, refer the case to your supervisor. 3. The patient was transported from and to points listed below. (a) From patients residence (or other place where need arose) to hospita l or skilled nursing facility.  3. Claims should show the ZIP Code of the point of pickup. (a) i. Condition met if trip began within the institutions service area as shown in the A/B MAC (B)s locality guide.  ii. Condition met where the trip began outside the institutions service area if the institution was the nearest one with appropriate facilities.  NOTE: A patients residence is the place where
(Medicare Benefit Policy Manual)
the A/B MAC (B)s locality guide.  ii. Condition met where the trip began outside the institutions service area if the institution was the nearest one with appropriate facilities.  NOTE: A patients residence is the place where he or she makes his/her home and dwells permanently, or for an extended period of time.  A skilled nursing fa cility is one, which is listed in the Directory of Medical Facilities as a participating SNF or as an institution which meets 1861(j)(1)  of the Act.  NOTE:  A claim for ambulance service to a participating  hospital or skilled nursing facility should not be denied on the grounds that there is a nearer nonparticipating institution having appropriate facilities. (b) Skilled nursing facility to a hospital or hospital to a skilled nursing facility.  (b) (i) Condition met if the ZIP Code of the pickup point is within the service area of the destination as shown in the A/B MAC (B)s locality guide.  (ii) Condition met where the ZIP Code of the pickup point is outside the service area of the destination if the destination institution was the nearest appropriate facility.  Cond itions  Review Action  (c) Hospital to hospital or skilled nursing facility to skilled nursing facility.  (c) Condition met if the discharging institution was not an appropriate facility and the admitting institution wa s the nearest appropriate facility.  (d) From a hospital or skilled nursing facility to patients residence.  (d) (i) Condition met if patients residence is within the institutions service area as shown in the A/B MAC (B)s locality guide.  (ii) Condition met where the patients residence is outside the institutions service area if the institution was the nearest appropriate facility.  (e) Round trip for hospital or participating skilled nursing facility inpatients to the nearest hospital or nonhospital tr eatment facility.  (e) Condition met if the reasonable and necessary diagnostic or therapeutic service required by patients condition is not available at the institution where the beneficiary is an inpatient.  NOTE:   Ambulance service to a physicians offi ce or a physician -directed clinic is not covered.  See 10.3. 8 above, where a stop is made at a physicians office en route to a hospital and 10.3.3  for additional exceptions.)  4. Ambulance services involving hospital admissions in
(Medicare Benefit Policy Manual)
clinic is not covered.  See 10.3. 8 above, where a stop is made at a physicians office en route to a hospital and 10.3.3  for additional exceptions.)  4. Ambulance services involving hospital admissions in Canada or Mexico are covered (Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 10.1.3.) if the following conditions are met:  4. (a) The foreign hospitalization has been determined to be covered; and  (b) The ambulance service meets the coverage requirements set forth in 10- 10.3.  If the foreign hospitalization has been determined to be covered on the basis of emergency services (See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 10.1.3), the necessity requirement (10.2) and the destination requirement ( 10.3 ) are considered met.  5. The A/B MAC (B) will make partial payment for otherwise covered ambulance service, which exceeded limits defined in item 6.  The A/B MAC (B) will base the payment on the amount payable had the patient been transported:  5 & 6 (a)  From the pickup point to the nearest appropriate facility, or  5 & 6 (b) From the nearest appropriate facility to the beneficiarys residence where he or she is being returned home from a distant institution.   20.1 - Mandatory Assignment Requirements (Rev. 1, 10- 01-03)
(Medicare Benefit Policy Manual)
When an ambulance prov ider/supplier, or a third party under contract with the provider/supplier, furnishes a Medicare -covered ambulance service to a Medicare beneficiary and the service is not statutorily excluded under the particular circumstances, the provider/supplier must s ubmit a claim to Medicare and accept assignment of the beneficiary's right to payment from Medicare.   20.1.1 - Managed Care Providers/Suppliers  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Mandatory assignment for ambulance services, in effect with the implementation of the ambulance fee schedule, applies to ambulance providers/suppliers under managed care as well as under fee -for-service.  The ambulance fee schedule is effective for claims with a date of service on or after April 1, 2002.  Any provider or supplier without a contract establishing payment amounts for services provided to a beneficiary enrolled in a Medicare Advantage (MA) coordinated care plan or MA private fee -for-service plan must accept, as pay ment in full, the amounts that they could collect if the beneficiary were enrolled in original Medicare.  The provider or supplier can collect from the MA plan enrollee the cost -sharing amount required under the MA plan, and collect the remainder from the MA organization.  20.1.2 - Beneficiary Signature Requirements  (Rev. 190, Issued: 07- 11-14, Effective: 08- 12-14, Implementation: 08- 12-14)  Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of acc epting assignment and submitting a claim to Medicare.  If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary:    (1) The beneficiarys legal guardian.   (2) A relative or other person who receives social security or other governmental benefits on behalf of the beneficiary.   (3) A relative or other person who arranges for the beneficiarys treatment or exercises other responsibility for his or her affairs.   (4) A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services, or assistance to the beneficiary.
(Medicare Benefit Policy Manual)
(4) A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services, or assistance to the beneficiary.   (5) A representative of the provider or of the nonparticipating hospit al claiming payment for services it has furnished, if the provider or nonparticipating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1  4).   (6) A representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least 4 years from the date of service.  A provider/supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign.  Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits.  When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment.  ( Note:  there is a 12 month period for filing a Medicare claim, depending upon the date of service.)  If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, then the ambulance provider/supplier may not bill Medicare, but may bill the beneficiary (or his or her estate) for t he full charge of the ambulance items  and services furnished. If, after seeing this bill, the beneficiary/representative decides to have Medicare pay for these items and services, then a beneficiary/representative signature is required and the ambulance pr ovider/supplier must afford the beneficiary/representative this option within the claims filing period.   30 - Implementation of the Ambulance Fee Schedule  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)