Medicare covers ambulance services, only if they are furnished to a beneficiary whose medical condition is such that use of any other means of transportation is contraindicated. A beneficiary whose condition permits transport in any type of vehicle, other than an ambulance, would not qualify for services under Medicare. The beneficiary's condition at the time of the transport is the determining factor in whether medical necessity is met.
A. Emergency Ambulance Services (Ground):
Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support, Level 1 (ALS1) level of service to a 911 call or the equivalent in areas without a 911 call system. Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of the closest appropriate facilities, and are provided by an ambulance service that is licensed by the state.
Medical reasonableness is established if the beneficiary's condition is an emergency, and the beneficiary is unable to go to the hospital by other means. An emergency means services provided after the sudden onset of a medical condition, manifesting itself by acute signs or symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the beneficiary's health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.
Examples of emergency situations are: (Note: this list is not all inclusive)
1. Injury resulting from an accident, or illness with acute symptoms. Examples are hemorrhage, shock, chest pain, acute neurological symptoms or respiratory distress.
2. The beneficiary requires restraints by a professionally trained ambulance attendant as a means of preventing injury either to the beneficiary or to another person. A description of why restraints are necessary is required. Such descriptions may include narrative describing specific violent or psychotic acts, frequency/severity/predictability of seizure activity, or a precise description of the risk to safety that unrestrained and unsupervised transport would create. A sole diagnosis of senility, forgetfulness, or Alzheimer's does not qualify.
3. Oxygen is required by the beneficiary during transport. The administration of oxygen itself does not satisfy the requirement that the beneficiary needed oxygen. Documentation should reflect the need for oxygen administration, such as hypoxemia, syncope, airway obstruction, and chest pain. Ambulance transport is not medically necessary if the only reason for the ambulance service is to provide oxygen during transport, and the beneficiary has a portable oxygen system available.
4. Immobilization of the beneficiary is necessary because of a suspected fracture, a compound fracture, severe pain, the need for pain medication, or suspicion of neurological injury.
5. A transfer is made of a beneficiary between institutions for necessary services not available at the transferring institution and the beneficiary meets any of the criteria 1-4 above. Examples are beneficiaries with cardiac disease requiring cardiac catheterization or coronary bypass not available at the transferring institution.
B. Non-Emergency (Scheduled) Ambulance Service (Ground):
Three criteria determine whether a beneficiary has Medicare coverage for non-emergency (scheduled) ambulance services:
* Only when transportation by any other means of transportation is contraindicated by the medical condition of the beneficiary;
* Only to specific destinations; and
* Only when certified as medically necessary by a physician directly responsible for the beneficiary's care
NOTE: All 3 of the above criteria must be met.
Ambulance transport in non-emergency situations must meet medical necessity guidelines.
1. Medical reasonableness is established for non-emergency ambulance services when the beneficiary's condition is such that the use of any other method of transportation (e.g., taxi, private car, wheelchair van, or other type of vehicle) is contraindicated.
NOTE: Bed confinement does not include a beneficiary who is restricted to bed rest on a physician's instructions due to a short-term illness. Bed confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply 1 element of the beneficiary's condition that may be taken into account in the A/B MAC determination of whether means of transport, other than an ambulance, were contraindicated. Examples of situations in which beneficiaries are bed-confined and cannot be moved by wheelchair, but must be moved by stretcher include:
a. Contractures creating non-ambulatory status and the beneficiary cannot sit
b. Severe generalized weakness
c. Severe vertigo causing inability to remain upright
d. Immobility of lower extremities (beneficiary is in a spica cast, fixed hip joints, or lower extremity paralysis) and unable to be moved by wheelchair
2. If some means of transportation other than an ambulance (e.g., private car, wheelchair van, etc.) could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.
3. If transportation is for the purpose of receiving an excluded service (e.g., a routine dental examination) then the transportation is also excluded even if the beneficiary could only have gone by ambulance.
4. If transportation is for the purpose of receiving a service that could have been safely and effectively provided at the point of origin, then the transport is not covered even if the beneficiary could only have gone by ambulance. Examples include: (a) A transport from a residence to a hospital for a service that can be performed more economically in the beneficiary's home, and (b) A transport of a Skilled Nursing Facility (SNF) beneficiary to a hospital or to another SNF for a service that can be performed more economically in the first SNF.
5. Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable and necessary (i.e., other means contraindicated).
C. Emergency Air Ambulance Transportation:
Emergency response means responding immediately at the BLS or ALS1 level of service to a 911 call or the equivalent in areas without a 911 call system. 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. Medically appropriate air ambulance transportation, either by means of a helicopter or fixed wing aircraft, is a covered service, regardless of the state or region in which it is rendered, only if the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance, or either:
A. The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or
B. Great distances or other obstacles (i.e., heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities as described in this policy.
NOTE: If the transport is for the purpose of receiving a non-covered service, then the transport is also non-covered, even if the destination is an appropriate facility.
Physician Certification & Order:
Ambulance transport providers or suppliers must obtain a written order from the attending physician for all non-emergency, scheduled repetitive ambulance services and a written statement from the physician certifying the medical necessity of the ambulance services. Requirements for non-emergency ambulance transportation include:
1. The order and certification must be dated no earlier than 60 days in advance of the transport, for repetitive beneficiaries whose transportation is scheduled in advance.
2. For residents in facilities who are under the direct care of a physician, written orders from the patient's attending physician certifying medical necessity can be obtained within 48 hours after the transport.
3. The physician order may be signed by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) (where all applicable state licensure or certification requirements are met).
4. For unscheduled non-emergency transports, a registered nurse (RN) or discharge planner, who is employed by the beneficiary's attending physician or the hospital or facility where the patient is being treated, may sign a physician certification statement on oral orders from the physician or other qualified practitioner (i.e., PA, NP, CNS).
5. A physician order is not required prior to emergency transports or unscheduled transports of a beneficiary residing at home or in a facility, who is not under the direct care of a physician.
NOTE: It is important to note that the presence of the signed physician certification statement does not necessarily demonstrate that the transport was medically necessary.