Highmark Medicare Advantage Medical Policy in West Virginia
Section: CMS National Guidelines
Number: N-84
Topic: Air Ambulance Services (See Reference Section)
Effective Date: July 27, 2009
Issued Date: July 27, 2009

General Policy

For services prior to July 27, 2009, see policy T-3.

Medically appropriate air ambulance transportation is a covered service regardless of the State or region in which it is rendered. However, claims may be approved only if the member’s medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate.

There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. The higher operational costs of the two types of aircraft are recognized with two distinct payment amounts for air ambulance mileage. The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown and is expressed in statute miles (not nautical miles).

  1. Fixed Wing Air Ambulance (FW)(A0430)
    Fixed wing air ambulance is furnished when the member’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the member’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the member is inaccessible by a ground or water ambulance vehicle.

  2. Rotary Wing Air Ambulance (RW)(A0431)
    Rotary wing air ambulance is furnished when the member’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the member’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the member is inaccessible by a ground or water ambulance vehicle.

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting members with acute medical conditions. The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. Ambulances must be staffed by at least two people, with at least one of them certified by the State or local authority at the appropriate level of first aid training.

Indications and Limitations of Coverage

Air ambulance transportation services, either by means of a helicopter or fixed wing aircraft, may be determined to be covered only if:

  1. The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States); or

  2. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities. (For information on hospitals with appropriate facilities, see the Hospital to Hospital Transport section of this policy.)

Additionally, payment may be made for an air ambulance service when the air ambulance takes off to pick up a member, but the member is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene). This is provided the air ambulance service would otherwise have been medically necessary. In such a circumstance, the allowed amount is the appropriate air base rate, i.e., fixed wing or rotary wing. However, no amount shall be allowed for mileage or for a rural adjustment that would have been allowed had the transport of a living member or of a member not yet pronounced dead been completed.

For the purpose of this policy, a pronouncement of death is effective only when made by an individual authorized under State law to make such pronouncements.

This policy also states no amount shall be allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight. Further, no amount shall be allowed if the aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but not actually taken off.

Medical Reasonableness 
Medical reasonableness is only established when the member’s condition is such that the time needed to transport a member by ground, or the instability of transportation by ground, poses a threat to the member’s survival or seriously endangers the member’s health. Following is an advisory list of examples of cases for which air ambulance could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed.

Time Needed for Ground Transport 
Differing Statewide Emergency Medical Services (EMS) systems determine the amount and level of basic and advanced life support ground transportation available. However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the member’s life or health. As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport a member whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the member’s illness/injury, air transportation is considered to be appropriate.

Mileage
Covered air ambulance mileage services are paid when the appropriate procedure code is reported on the claim:

Air mileage must be reported in whole numbers of loaded statute miles flown. The appropriate air transport code must be used with the appropriate mileage code.

Air ambulance services may be paid only for ambulance services to a hospital. Other destinations e.g., skilled nursing facility, a physician’s office, or a patient’s home may not be paid air ambulance. The destination is identified by the use of an appropriate modifier.

Claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Additional air mileage may be allowed in situations where additional mileage is incurred due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

If the air transport meets the criteria for medical necessity, payment may be made for the actual miles flown for legitimate reasons, once the member is loaded onto the air ambulance.

No Transport
The ambulance benefit is a transportation benefit. If no transport of a member occurs (A0998), then there is no covered service. This policy applies to situations in which the member refuses to be transported, even if medical services are provided prior to loading the member onto the ambulance (e.g., BLS or ALS assessment). However, the entity that furnishes a non-covered service to a member may bill the member for the service.

Hospital to Hospital Transport 
Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the member’s health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician.

Special Payment Limitations
If a determination is made that transport by air ambulance was necessary, but ground ambulance service would have sufficed, payment for the air ambulance service is based on the amount payable for ground transport, if less costly.

If the air transport was medically appropriate (that is, ground transportation was contraindicated, and the member required air transport to a hospital), but the member could have been treated at a nearer hospital than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.

Billing for Ground-to-Air Ambulance Transports
For situations in which a member is transported by ground ambulance to or from an air ambulance, the ground and air ambulance providers/suppliers providing the transports must bill independently. Under these circumstances, payment will be made to each provider/supplier individually for its respective services and mileage. Each provider/supplier must submit a claim for its respective services/mileage.

Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot’s Control 
The chart below shows the payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilot’s control.

Air Ambulance Scenarios: Aborted Flights

Aborted Flight Scenario

Payment Determination
Any time before the member is loaded onboard (i.e., prior to or after take-off to point-of-pickup.) None
Transport after the member is loaded onboard. Appropriate air base rate, mileage, and rural adjustment.


Effect of Member Death on Payment for Air Ambulance Transports
Because the ambulance benefit is a transport benefit, if no transport of a member occurs, then there is no covered service. In general, if the member dies before being transported, then no payment may be made. Thus, in a situation where the member dies, whether any payment under the ambulance benefit may be made depends on the time at which the member is pronounced dead by an individual authorized by the State to make such pronouncements.

The chart below shows the payment determination for various air ambulance scenarios in which the member dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary. If the flight is aborted for other reasons, such as bad weather, the payment determination is based on whether the member was onboard the air ambulance.

Air Ambulance Scenarios: Member Death

Time of Death Pronouncement

Payment Determination
Prior to takeoff to point-of-pickup with notice to dispatcher and time to abort the flight. None.
NOTE: This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off.
After takeoff to point-of-pickup, but before the member is loaded. Appropriate air base rate with no mileage or rural adjustment; use the QL modifier when submitting the claim.
After the member is loaded onboard, but prior to or upon arrival at the receiving facility. As if the member had not died.

The supplier must submit documentation with the claim sufficient to show that:

  1. The air ambulance was dispatched to pick up a member;
  2. The aircraft actually took off to make the pickup;
  3. The member to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport;
  4. The pronouncement of death was made by an individual authorized by State law to make such pronouncements; and
  5. The dispatcher did not receive notice of such pronouncement in sufficient time to permit the flight to be aborted before take off.

Reasons for Noncoverage

The Medicare ambulance benefit is a transportation benefit and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport. Ambulance providers/suppliers that arrive on the scene but do not furnish a transport are not due payment.

No payment may be made for the transport of ambulance staff or other personnel when the member is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a member at another hospital). This policy applies to both ground and air ambulance transports.

Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or a member’s home.

Items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services. This occurred when CMS fully implemented the Ambulance Fee Schedule, and therefore, payment is based solely on the ambulance fee schedule.

Documentation Requirements

In order to determine the medical appropriateness of air ambulance services, documentation may be requested that indicates the air ambulance services are reasonable and necessary to treat the member’s life-threatening condition. The medical staff may consider reviewing all claims for air ambulance services.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

A0430A0431A0435A0436A0998 

Coding Guidelines

Publications

References

CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10, Sections 10, 10.1.1, 10.1.2, 10.2.5, 10.4, 10.4.1, 10.4.2, 10.4.3, 10.4.4, 10.4.5, 10.4.6, 10.4.7, 10.4.8, 10.4.9

CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 15, Sections 10.4, 20.3

Transmittal AB-03-007, CR 2470

Transmittal AB-02-131, CR 2297

Transmittal AB-02-031, CR 1961

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.