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Medical Policy

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

Ambulance Services

MPM 1.1

  • 4.

    Center for Medicare and Medicaid Services, Novitas Local Coverage Determination for Ambulance Services (L28627). Original Determination Effective Date: 11-14-13.

  • 5.

    Presbyterian Health Plan, Benefit Interpretation Manuals for Commercial, Medicare Advantage and SCI

Approval Signatures:

Clinical Quality Committee:

Ron Parton MD

Medical Director:

Norman White MD


January 29, 2014

Publishing History:

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

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