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Medical Policy

Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 2 of 5

Ambulance Services

MPM 1.1

Weather or traffic conditions exist which make ground ambulance impractical, impossible or overly time consuming. If a member dies before an air ambulance arrives, the air ambulance is covered for the initial leg of trip, IF the air ambulance began its trip before the member died. Payment will be made according to the appropriate fee schedule or provider contract. 7. Origin and destination information all requirements noted above apply:

Ambulance services are covered from any point of origin to the nearest hospital or skilled-nursing facility (SNF) that is capable of furnishing the required level and type of care for the members illness or injury. Ambulance services are covered from a hospital or SNF to the members home. Ambulance services are covered from a SNF to the nearest supplier of medically necessary services not available at the SNF where the member is a resident, including the return trip.

Non-emergency ambulance transportation is not covered if the service could have been safely and effectively provided at the point of origin (residence, SNF, hospital, etc.). Such transportation is not covered even if the patient could only have gone for the service by ambulance.

Ambulance services are covered for dialysis treatment for ESRD patients from the members home to the nearest facility that furnishes renal dialysis, including the return trip, when all of the above requirements are met.

Documentation Requirements

It is the responsibility of the ambulance supplier to maintain, and furnish if requested, complete and accurate documentation of the beneficiary’s condition to demonstrate the ambulance service is medically necessary and meets criteria. The following documentation may be required:

Physician certification of medical necessity. For repetitive services, this certification should be dated no earlier than 60 days before the date of the service. Please note: See Trailblazer’s LCD L28627 for circumstances when providers other than a physician may provide a certificate of medical necessity for non-repetitive non-emergent transports.

Detailed description of the patients condition at the time of transport, which must be consistent with other supporting medical documentation. This description should report symptoms, functional status, any traumatic event, existing safety issues, any special precautions taken, and any special monitoring undertaken. Point of pickup, number of miles, dispatch record.

Not every Presbyterian health plan contains the same benefits. Please refer to the members specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC080901]

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