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Medical Policy

Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 3 of 5

Ambulance Services

MPM 1.1

Exclusions

Definitions

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:

  • o

    Inability to get up from the bed without assistance.

    • o

      Inability to ambulate.

    • o

      Inability to sit in a chair or a wheelchair.

Ambulances services are not covered in the following circumstances:

  • 1.

    Any ambulance service that is not medically necessary.

  • 2.

    Ambulance services used as a convenience for either the member or family.

  • 3.

    Ambulance service when the member refuses assessment, treatment or transportation.

  • 4.

    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.

  • 5.

    Ambulance service (ground or air) if the member is pronounced dead prior to the time the ambulance is called.

  • 6.

    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 members 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 persons 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 members specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC080901]

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