Source: http://medpolicy.ibx.com/policies/mpi.nsf/f12d23cb982d59b485257bad00552d87/b8d774839ded7dba85258376004dbb69!OpenDocument
Timestamp: 2019-04-22 08:46:39+00:00

Document:
The services provided are medically necessary to stabilize the individual’s medical condition.
The responding Emergency Medical Services (EMS) ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured.
The responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency.
The EMS staff is able to provide assessment, monitoring, assistance, treatment and observation during transportation.
Transportation of the individual will be from the individual’s home, or the scene of the accident or medical emergency, to the nearest acute care hospital or other Emergency Care Facility, where emergency health services can be provided to the individual.
The necessary diagnostic and/or therapeutic services are not available at the facility in which the member is located.
Supplies that are needed to stabilize an individual’s medical condition are considered medically necessary and, therefore, covered when the emergency ambulance service with transport is medically necessary.
Emergency ground ambulance services without transportation of an individual to an emergency facility is considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.
Nonemergency ambulance transport benefit requirements are met when nonemergency ambulance transport is outlined as a benefit according to the member contract. Member contracts may variously limit or exclude the eligibility of the transport origin, transport destination, type of provider or transport (e.g., nonemergency ambulance transport), and/or the participation status of the transport provider. Individual member benefits must be verified.
This requirement is met when the nonemergency ambulance transport is requested to obtain a covered treatment or service for an individual or to return an individual from having obtained a covered treatment or service. A treatment or service is considered covered when it is identified in the member contract as a benefit and the individual meets the medical necessity criteria required to obtain the treatment or service. When a treatment or service for which an individual has a benefit does not meet medical necessity requirements, nonemergency ambulance transport for that treatment or service is considered not medically necessary and, therefore, not covered.
The origin is not precluded from eligibility in the member contract.
The destination is not precluded from eligibility in the member contract.
The destination has the facilities to treat the individual’s condition.
If covered, medically necessary services can be otherwise provided quickly, equally as safely, and more cost efficiently to the individual than by nonemergency ambulance transport, the transport is considered to be not medically necessary. For example, the transport of an individual to receive wound care is not considered reasonable if the wound care could be provided at the individual's bedside at less cost than transporting the individual to a facility to obtain the services.
In products requiring precertification, a medical necessity determination is based on the medical information received at the time of the request for the service.
The individual's condition at the time of transport must require the presence of medical personnel who are certified and/or licensed to provide monitoring and/or interventional medical services.
The individual has to remain immobile because of a fracture that has not been set or because of the possibility of a fracture (e.g., hip fracture).
The individual is in a body cast or spica cast.
The individual is bed-confined before and after transport (refer to the Description section of this policy for a definition of bed-confined).
The individual is unable to sit in a chair or wheelchair for the duration of the transport.
The individual has lower extremity contractures that are of sufficient degree as to prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).
Morbid obesity (as a sole qualifying condition) caused the individual to meet the definition of bed-confined.
The individual has a health condition(s) that would be exacerbated by transport in a vehicle other than an ambulance.
The individual must remain in a supine/prone position.
Post-hip replacement individuals may sit in a chair slightly higher than the average seat (e.g., wheelchair). Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement.
Post-knee replacement individuals should be able to bend their knee approximately 90 degrees at the time of discharge. Therefore, in most cases, this condition alone does not satisfy the medical necessity requirement.
The individual requires maintenance of medical isolation precautions for active infectious processes.
The individual requires a skilled service during transport (e.g., ventilator care, nursing).
The individual is not able to self-administer oxygen or requires active assistance with its administration by medical personnel during transport.
The individual requires the continuation of oxygen therapy that was initiated during the immediate hospitalization from which the transport is being requested and the individual does not have portable oxygen equipment at the time of the transport request.
A roundtrip nonemergency ground ambulance transport between an eligible point of origin (as defined above) and an eligible destination (as defined above) for an individual to receive eligible medical services not otherwise available at the point of origin is considered medically necessary and therefore covered, when requirements (1) through (5) in this policy are met. Roundtrip nonemergency ground ambulance transport must be reported with the appropriate origin and destination modifier for each segment corresponding to the origin and destination of the roundtrip transport.
The letter of medical necessity must be dated no later than 60 days in advance of the transport for those individuals who require repetitive ambulance services and whose transportation is scheduled in advance.
The transport of multiple individuals in the same ambulance vehicle is eligible for separate reimbursement consideration only when the nonemergency ambulance transport would have otherwise been covered and eligible for reimbursement consideration if provided to each individual separately.
The nonemergency ambulance transport record indicates that unusual circumstances existed to necessitate the presence of extra attendants.
Disposable supplies (e.g., gauze, dressings, cervical collars) that are utilized in excess of the amount that would be considered appropriate in the treatment of the individual's medical condition are eligible for separate reimbursement consideration only when the nonemergency ambulance transport record indicates that unusual circumstances existed and when the applicable provider contract has a provision for such services.
All scheduled ground ambulance transports will be considered nonemergency. Transports to nursing homes, places of residence, and ESRD facilities will be considered nonemergency.
Nonemergency ground ambulance services without transportation of an individual, even if medical services are provided to the individual, is considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.
The individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode.
Reusable devices and equipment (e.g., backboards, neck boards, inflatable splints) are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are included in the reimbursement for the transport.
Waiting time is not eligible for separate reimbursement because it is always integral to the primary nonemergency ambulance transport code with which it is reported.
The vehicle and crew utilized for emergency and nonemergency ambulance transport should meet all applicable local, state, and federal regulatory, certification, and licensing requirements.
If an emergency occurs during a nonemergency ambulance transport, the Company considers it an emergency ambulance transport only if the individual's condition meets the Company's definition of an emergency condition (refer to the Description section of this policy for the definition of emergency).
Subject to the terms and conditions of the applicable benefit contract, ground ambulance services are covered under the medical benefits of the Company’s products when the criteria listed in this policy are met.
Subject to the terms and conditions of the applicable benefit contract, ground ambulance services that do not satisfy the criteria listed in this policy are considered not medically necessary.
The application of benefits may vary by product and/or group; therefore, individual member benefits must be verified.
In products without an Out-of-Network benefit (HMO), non-emergency ground transport may be covered to transport the member back to an In-Network Facility Provider in the member's service area as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator], when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.
In products with an Out-of-Network benefit (PPO and the POS product) non-emergency ground transport may be covered to transport the Member back to an In-Network Facility Provider as determined by the [(Fully-Insured) Health Benefit Plan or (Self-Insured) Claims Administrator] when the transfer is medically necessary (as determined by the company’s definition of medical necessity); AND the member's medical condition requires uninterrupted care and attendance by qualified medical staff during ground transport. Transportation back to the member's service area is not covered for family members or companions as it is a benefit contract exclusion.
This policy is in compliance with federal, state, and local mandates.
Ground ambulance transport services may involve ground or water transport in both emergency and nonemergency situations.
A ground ambulance vehicle is designed and equipped to respond to medical emergencies and for the transport of individuals who are sick or injured. The vehicle must comply with state and local laws governing the licensing and certification of an emergency medical transportation vehicle and is staffed by state certified or qualified staff who are able to provide basic life support or advanced life support services, as appropriate.
A sea ambulance is a watercraft used for emergency medical assistance in situations where either a ground ambulance cannot reach the scene easily or quickly enough, or the individual needs to be transported over a distance or terrain that makes water transportation the most practical transport mode. Sea ambulance crews are supplied with equipment that enables them to monitor and provide medical treatment to an individual during transportation.
Appropriate facilities are generally equipped and staffed to provide the necessary care for the individual's health condition. In the case of an acute care hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the individual's condition.
Home is defined as the individual's place of residence (e.g., private residence/domicile, assisted living facility, long-term care facility, skilled nursing facility [SNF] at a custodial level of care).
Emergency response means responding immediately at the basic life support (BLS) or advanced life support (ALS) level of services to a 911 call or the equivalent, for the transportation of an individual due to a sudden onset of a medical condition, requiring medical assessment, monitoring, treatment or observation of the individual. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.
Nonemergency ambulance transport is an ambulance transport provided for an individual who has nonemergent conditions but still requires ambulance transportation because other methods of transportation are contraindicated (e.g., bed confinement status, need for continuous supervision, physical restraint status, and/or dependence on other enabling machines and devices). Nonemergency ambulance transport may be provided at either a basic life support (BLS) or an advanced life support (ALS) level of care.
American College of Emergency Physicians (ACEP). Policy Statements. Appropriate interfacility patient transfer. [ACEP Web site]. Original: 09/1989. (Revised 01/2016). Available at:https://www.acep.org/patient-care/policy-statements/appropriate-interfacility-patient-transfer/#sm.00006vg9fr1bakdtbz9sgovgpzj01. Accessed September 12, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. SE1514: Overview of the repetitive scheduled non-emergent ambulance prior authorization model. [CMS Web site]. Original:05/04/2015. (Revised 02/14/2018). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1514.pdf. Accessed August 8, 2018.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services. §30.1. Definition of ambulance services. [CMS Web site].(Revision #243: 04/13/18). Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance services. [CMS Web site]. (Revision #243: 04/13/18). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4 - Benefits and beneficiary protections. §20.2. Definitions of emergency and urgently needed services. [CMS Web site]. (Revision #121: 04/22/16). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf.Accessed August 8, 2018.
Commonwealth of Pennsylvania. PA Code 28, Ch 9, §9.602. Definitions. [The Pennsylvania Code Web site]. Available at: https://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 40, Subchapter 1, §8:40-1.3. Mobility assistance vehicle and basic life support ambulance services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac840ar.pdf. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41, Subchapter 1, §8:41-1.3. Advanced life support services; mobile intensive care programs, specialty care transport services and air medical services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41a, Subchapter 1, §8:41a-1.3. Emergency Medical Technicians - Paramedic: training and certification. [NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=51&Keyword=ambulance&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed September 10, 2018.
Pennsylvania Department of Health. Bureau of Emergency Medical Services. EMS Information Bulletin 2012-08. 05/03/12. Available at:http://www.health.pa.gov/My%20Health/Emergency%20Medical%20Services/EMS%20in%20PA/Documents/2012/EMSIB%202012-008-Stretcher%20Vans.pdf. Accessed August 8, 2018.
This policy was updated to revise policy coverage criteria regarding Ground Ambulance Services.
08/13/2018 Effective 08/13/2018, this policy has been reviewed and reissued to communicate the Company’s continuing position on Nonemergency Ambulance Transport Services.

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