Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 3 of 5
For hospital-to-hospital transport, indicate specific treatment or specialist. Bed confinement is not a sole criterion in determining medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations. To be considered as bed-confined, the following criteria must be met:
Inability to get up from the bed without assistance.
Inability to ambulate.
Inability to sit in a chair or a wheelchair.
Ambulances services are not covered in the following circumstances:
Any ambulance service that is not medically necessary.
Ambulance services used as a convenience for either the member or family.
Ambulance service when the member refuses assessment, treatment or transportation.
Air ambulance when the time required to transport the member by ground ambulance poses no threat and the point of pick-up is accessible by a land vehicle.
Ambulance service (ground or air) if the member is pronounced dead prior to the time the ambulance is called.
Non-emergency wheelchair transport (a specially-designed vehicle equipped with a wheelchair lift or other modifications to transport a patient in a wheelchair).
Medical Necessity for Ambulance Transfer: The member’s condition is such that other means of transportation are contraindicated.
Ambulance Service: A licensed transportation service, capable of providing medically necessary life support care in the event of a life- threatening emergency.
Emergency Ambulance Services: Ambulance services provided after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a reasonable layperson, to result in:
Jeopardy to the person’s health Serious impairment of bodily functions Serious dysfunction of any bodily organ or part Disfigurement to the person
High-risk Ambulance: Ambulance services that are non-emergent but medically necessary for a high-risk patient and ordered by a physician. This does not include mental health conditions and/or circumstances.
Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC080901]