To be covered, ambulance transportation must be medically necessary. Medical necessity is established when the individual’s clinical condition is such that the use of any other method of transportation, such as taxi, private car, or other type of vehicle would be contraindicated (i.e., would endanger the individual”s medical condition).
The individual’s condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the individual is elderly, has a positive medical history, or cannot care for himself/herself does not establish medical necessity.
Additionally, stair safety concerns or the individual’s inability to negotiate stairs, in the absence of another medical condition that meets medical necessity criteria, does not satisfy medical necessity criteria.
Benefits are not available for ambulance services when an ambulance was used simply for convenience or because other means of transportation was not available, e.g. wheelchair van transport (A0130) and stretcher van transport (T2005, T2049).
Coverage may be available for expenses incurred by an individual for ambulance services that meet the following conditions (this is not an all-inclusive list):
- Was transported in an emergency situation, e.g., as a result of an accident, injury or acute medical or psychiatric illness; or
- Needed to be restrained; or
- Was unconscious or in shock; or
- Required oxygen (due to hypoxemia, syncope, airway obstruction or chest pain) or other emergency treatment on the way to the destination; or
- Had to remain immobile because of a fracture that had not been set or the possibility of a fracture (e.g., hip fracture, compound fracture, severe pain with need for intravenous pain medication or neurological injury); or
- Sustained an acute stroke or myocardial infarction; or
- Was experiencing severe hemorrhage; or
- Was bed confined before and after the ambulance trip (see note below); or
- Could be moved only by stretcher because of a specific physical condition or limitation; or
- Lower extremity contractures creating non-ambulatory status and the individual cannot sit in a wheelchair (severe fixed contractures proximal to the knee); or
- Severe generalized weakness from a health condition that would be exacerbated by transport in a vehicle other than an ambulance; or
- Severe vertigo causing inability to remain upright; or
- Immobility of lower extremities (Spica or full body cast, fixed hip joints or lower extremity paralysis and unable to be moved by wheelchair).
NOTE: Post-hip replacement individuals may sit in a chair slightly higher than the average seat. 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. This condition alone does not satisfy the medical necessity requirement.
NOTE: “Bed confinement” is defined as (all three conditions must be met):
The individual is:
- Unable to get up from bed without assistance; and
- Unable to ambulate; and
- Unable to sit in a chair or wheelchair.
Non-emergency ambulance transportation is not covered for individuals who are restricted to bed rest by a physician’s instructions but who do not meet the above three criteria. If some means of transportation other than an ambulance (i.e., private car, wheelchair van, etc.) could be utilized without endangering the individual’s health, regardless if such other transportation is actually available, no payment may be made for ambulance service.