Description

Air and water ambulance vehicles are specially equipped to transport individuals with life threatening emergencies to the hospital.

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

NON-EMERGENCY TRANSPORT*
Non-emergency air or water ambulance services may be considered medically necessary when ALL of the following criteria are met:

• The individual's medical condition requires uninterrupted care and attendance by qualified medical staff during transport; and
• The individual's medical condition requires transport that cannot be provided by land ambulance; and
• Great distances, limited timeframes, or other obstacles are involved in transporting the individual; and
• ALL of the following destination criteria are met: 
  • The destination is a covered facility according to the member contract; and
  • The destination has the appropriate facilities to treat the individual’s condition.

*Non-emergency air or water ambulance transport is NOT covered for the convenience of the member, family members/companions, or the provider treating the member.

Examples of non-covered air or water ambulance transportation:

• Air or water emergency transportation used to transport member to a facility for treatment because family or member wants treatment at that facility when there is an equally competent facility near member.
• Air or water transport utilized for individual in a foreign country to transport home for treatment when same competent treatment could have been completed in the foreign country.
• Air or water transport utilized for member or family’s convenience in a non-life threatening circumstance.

Procedure Codes

Vehicle and Crew Requirement

The vehicle and crew utilized for air or water ambulance transport must meet all applicable local, state, and federal regulatory certification and licensing requirements.

Wait Time

No additional benefits are available for wait time in situations where additional mileage or wait time is incurred due to circumstances beyond the ambulance pilot’s control.

Procedure Codes

Treatment, No Transport

Benefits will be provided when an ambulance responds, BLS or ALS treatment is provided, but no transport of the individual takes place (e.g. individual refuses.)

Benefits are not available if no treatment is provided. (e.g. individual pronounced dead before ambulance arrives)

Procedure Codes

Miscellaneous

• • Ambulance providers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).
  • More than one individual may be transported, e.g., from the scene of a traffic accident.
  • When multiple individual transports are reported, the statement “multiple individuals” and the number transported must be documented.
  • Ambulance services that are provided for individual or family convenience is not a covered benefit.