Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 5 of 5
Center for Medicare and Medicaid Services, Novitas Local Coverage Determination for Ambulance Services (L28627). Original Determination Effective Date: 11-14-13.
Presbyterian Health Plan, Benefit Interpretation Manuals for Commercial, Medicare Advantage and SCI
Clinical Quality Committee:
Ron Parton MD
Norman White MD
January 29, 2014
02-28-00: Original effective date for Commercial Benefit Interpretation
Manual, Revised 7-25-05. 01-22-01: Original effective date for Medicare Advantage Benefit
Interpretation Manual, Revised 07-22-02, 11-25-02, 06-23- 03, 06-28-04, 04-23-07. 06-27-06: Original effective date for State Coverage Insurance Benefit
Interpretation Manual. 12-07-07: Merging of Benefit Interpretation Manuals as noted above
into Medical Policy. 08-26-09: Annual update and revision. 11-30-11: Annual Review 01-29-14: Annual Review
This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. The Medical Policies are not a treatment guide and should not be used as such.
For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical directors in reviewing the case. Please note that all PHP Medical Policies are available online at: http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htm
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]