Criteria
Air and water ambulance transportation may be considered medically necessary when ALL the following criteria are met:
Emergent transport
BCBSND will only cover air ambulance services to the nearest appropriate medical facility, with the exception of well documented extraordinary circumstances (example: blizzard conditions); and
The individual’s medical condition must require immediate and rapid transportation that cannot be provided by land ambulance; and
At least ONE of the following:
- The point of pick-up is inaccessible by land vehicle; or
- Great distances or other obstacles (for example, heavy traffic) are involved in getting the individual to the nearest hospital with appropriate facilities for treatment. The term "appropriate facility” refers to a hospital that is capable of providing the required level and type of care for the individual’s illness and has available the type of physician or specialist needed to treat the individual’s condition.
Medical necessity for air or water transportation is established when the individual’s condition is such that the time needed to transport a member by land, or the instability of transportation by land, poses a threat to the individual’s survival or seriously endangers the member’s health.
Following is a list of examples of cases for which air or water ambulances could be justified; this list is not inclusive of all situations that justify air or water emergency transportation, nor is it intended to justify air or water emergency transportation in all locales for the circumstances listed.
- Intracranial bleeding which requires neurosurgical intervention; or
- Cardiogenic shock; or
- Major Burns requiring treatment in a Burn Center; or
- Conditions requiring treatment in a Hyperbaric Oxygen Unit; or
- Multiple severe injuries; or
- Life-threatening trauma; or
- High risk pregnancy – (high risk of preterm delivery or high medical risk to mother or fetus).
Transfers
The transfer of a individual from one hospital to another may be considered medically necessary if medical appropriateness criteria are met and the transferring hospital cannot provide the required level of care needed by the individual.
Examples of such services include:
- Burn units; or
- Cardiac care units; or
- Trauma units; or
- Neonatal intensive care units.
The ambulance transport is covered ONLY if the hospital to which the individual is transferred is the nearest with appropriate facilities.
Reimbursement will be made for medically necessary transport to the nearest appropriate facility.
Air and water ambulance transportation are considered not medically necessary when the above criteria have not been met.
Procedure Codes
| A0430 | A0431 | A0435 | A0436 | A0424 | A0999 |