DISCLAIMER

Highmark Health Options medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.

POLICY STATEMENT

Highmark Health Options may provide coverage under medical surgical benefits of the Company’s Medicaid products for medically necessary. Refer to the Noncovered Services policy for more information.

This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.

The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the West Virginia Department of Health and Human Resources (DHHR) and all applicable state and federal regulations.

Purpose 

This medical policy outlines Highmark Health Options services for  Air ambulance.

Definitions

Advanced Life Support, Level 1 (ALS1) – The transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including the provision of an ALS assessment by ALS personnel or at least one ALS intervention. An advanced life support (ALS) intervention is a procedure cordance with state and local laws, required to be done by an emergency medical technician intermediate (EMT-Intermediate) or EMT-Paramedic.

 

Advanced Life Support, Level 2 (ALS2) - The transportation by ground ambulance vehicle and the provision of medically necessary supplies and services including (1) at least three separate administrations of one of more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or (2) ground ambulance transport, medically necessary supplies and services, and the provision of any one of the ALS2 procedures listed below:

• Manual defibrillation/cardioversion

• Endotracheal intubation

• Central venous line

• Cardiac pacing

• Chest decompression

 • Surgical airway

 • Intraosseous line

 

Fixed Wing Air Ambulance (FW) - Fixed wing air ambulance is furnished when the patient's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the patient’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the patient is inaccessible by a ground or water ambulance vehicle

 

Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.

 

Rotary Wing Air Ambulance (RW) - Rotary wing air ambulance is furnished when the patient's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the patient's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the patient is inaccessible by a ground or water ambulance vehicle.

 

Rural Air Ambulance Services - Fixed wing and rotary wing air ambulance service in which the point of pickup of the individual occurs in a rural area (as defined in Section 1886(d)(2)(D)) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification, originally published in the Federal Register on February 27, 1992)) (57 Fed. Reg. 6725).

Prior Authorization

Prior Authorization may be required. Please validate codes on the Prior Authorization Lookup Tool

https://wv.highmarkhealthoptions.com/providers/prior-authorization-code-lookup.html

Procedures

Medically appropriate air ambulance transportation is a covered service regardless of the state or region in which it is rendered. However, claims may be approved only if the patient’s medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate.

 

There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. The higher operational costs of the two types of aircraft are recognized with two distinct payment amounts for air ambulance mileage. The air ambulance mileage rate is calculated per actual loaded (patient onboard) miles flown and is expressed in statute miles (not nautical miles).

 

Fixed Wing Air Ambulance (FW) (A0430) Fixed wing air ambulance is furnished when the patient’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the patient’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the patient is inaccessible by a ground or water ambulance vehicle.

 

Rotary Wing Air Ambulance (RW)(A0431) Rotary wing air ambulance is furnished when the patient’s medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the patient’s condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the patient is inaccessible by a ground or water ambulance vehicle.

 

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting patients with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state or local law.

 

1. Air ambulance transportation services, either by means of a helicopter/rotary wing or fixed wing aircraft, may be determined to be covered only if:

A. The vehicle and crew requirements are met;

B. The patient’s medical condition required immediate and rapid ambulance transportation that could not have been provided by ground ambulance; AND EITHER

 • The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States); OR

• Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities. (For information on hospitals with appropriate facilities, see the Hospital to Hospital Transport section of this policy.)

 

Additionally, payment may be made for an air ambulance service when the air ambulance takes off to pick up a patient, but the patient is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene). This is provided the air ambulance service would otherwise have been medically necessary. In such a circumstance, the allowed amount is the appropriate air base rate, i.e., fixed wing or rotary wing. However, no amount shall be allowed for mileage or for a rural adjustment that would have been allowed had the transport of a living patient or of a patient not yet pronounced dead been completed.

 

For the purpose of this policy, a pronouncement of death is effective only when made by an individual authorized under state law to make such pronouncements.

 

This policy also states no amount shall be allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight. Further, no amount shall be allowed if the aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but not actually taken off.

 

Medical Reasonableness

Medical reasonableness is only established when the patient’s condition is such that the time needed to transport a patient by ground, or the instability of transportation by ground, poses a threat to the patient’s survival or seriously endangers the patient’s health. Following is an advisory list of examples of cases for which air ambulance could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed.

• Intracranial bleeding – requiring neurosurgical intervention

• Cardiogenic shock

 • Burns requiring treatment in a burn center

• Conditions requiring treatment in a Hyperbaric Oxygen Unit

• Multiple severe injuries

• Life-threatening trauma

Time Needed for Ground Transport

 Differing Statewide Emergency Medical Services (EMS) systems determine the amount and level of basic and advanced life support ground transportation available. However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the patient’s life or health. As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport a patient whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the patient’s illness/injury, air transportation is considered to be appropriate.

 

Mileage

Covered air ambulance mileage services are paid when the appropriate procedure code is reported on the claim:

 • Procedure code A0435 identifies FIXED WING AIR MILEAGE.

• Procedure code A0436 identifies ROTARY WING AIR MILEAGE

 

Air mileage must be reported in whole numbers of loaded statute miles flown. The appropriate air transport code must be used with the appropriate mileage code.

 

Air ambulance services may be paid only for ambulance services to a hospital. Other destinations (e.g., skilled nursing facility, a physician’s office, or a patient’s home) may not be paid air ambulance. The destination is identified by the use of an appropriate modifier.

 

Claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Additional air mileage may be allowed in situations where additional mileage is incurred due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions

• Hazardous weather

 • Variances in departure patterns and clearance routes required by an air traffic controller

 

No Transport

The ambulance benefit is a transportation benefit. If no transport of a patient occurs (A0998), then there is no covered service. This policy applies to situations in which the patient refuses to be transported, even if medical services are provided prior to loading the patient onto the ambulance (e.g., BLS or ALS assessment). However, the entity that furnishes a non-covered service to a patient may bill the patient for the service.

 

Hospital to Hospital Transport

Air ambulance transport is covered for transfer of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the patient’s health and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to burn care, cardiac care, trauma care, and critical care. A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient’s family prefer a specific hospital or physician.

 

Limitations

 

HHO Duals does not cover the following services:

 

Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs

 • Transportation via Mobile Intensive Care Unit (MICU)

 • Parking fees

• Tolls for bridges, tunnels, and highways

 • HHO Duals does not provide payment for “Ambulance response and treatment, no transport (A0998).”

When appropriate, contractors shall describe the circumstances under which the proposed medical policy for the service is considered reasonable and necessary. Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

• Safe and effective

 • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, that meet the requirements of the Clinical Trials NCD are considered reasonable and necessary).

• Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:

o Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member.

o Furnished in a setting appropriate to the patient's medical needs and condition

 o Ordered and furnished by qualified personne

 o One that meets, but does not exceed, the patient's medical needs

 o At least as beneficial as an existing and available medically appropriate alternative

The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in this medical policy.

 

 

Special Payment Limitations

 If a determination is made that transport by air ambulance was necessary, but ground ambulance service would have sufficed, payment for the air ambulance service is based on the amount payable for ground transport, if less costly.

If the air transport was medically appropriate (that is, ground transportation was contraindicated, and the patient required air transport to a hospital), but the patient could have been treated at a nearer hospital than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.

 

Billing for Ground-to-Air Ambulance Transports

For situations in which a patient is transported by ground ambulance to or from an air ambulance, the ground and air ambulance providers/suppliers providing the transports must bill independently. Under these circumstances, payment will be made to each provider/supplier individually for its respective services and mileage. Each provider/supplier must submit a claim for its respective services/mileage.

 

 

 

 

Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilot’s Control

 

The chart below shows the payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilot’s control.

 

Air Ambulance Scenarios: Aborted Flights

Aborted Flight Scenario	Payment Determination
Any time before the patient is loaded onboard (i.e., prior to or after take-off to point-of-pickup).	None.
Transport after the patient is loaded onboard.	Appropriate air base rate, mileage, and rural adjustment.

 

Effect of Patient’s Death on Payment for Air Ambulance Transports

Because the ambulance benefit is a transport benefit, if no transport of a patient occurs, then there is no covered service. In general, if the patient dies before being transported, then no payment may be made. Thus, in a situation where the patient dies, whether any payment under the ambulance benefit may be made depends on the time at which the patient is pronounced dead by an individual authorized by the state to make such pronouncements. 

The chart below shows the payment determination for various air ambulance scenarios in which the patient dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary. If the flight is aborted for other reasons, such as bad weather, the payment determination is based on whether the patient was onboard the air ambulance.

 

Air ambulance Scenarios: Patient Death 

Time of Death Pronouncement	Payment Determination
Prior to takeoff to point-of-pickup with notice to dispatcher and time to abort the flight.	None. NOTE: This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off.
After takeoff to point-of-pickup, but before the patient is loaded.	Appropriate air base rate with no mileage or rural adjustment.
After the patient is loaded onboard, but prior to or upon arrival at the receiving facility.	As if the patient had not died.

In the event of a patient’s death, the supplier must submit documentation with the claim sufficient to show ALL of the following:

A. The air ambulance was dispatched to pick up a patient; AND

 B. The aircraft actually took off to make the pickup; AND

 C. The patient to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport; AND

D. The pronouncement of death was made by an individual authorized by state law to make such pronouncements; AND

E. The dispatcher did not receive notice of such pronouncement in sufficient time to permit the flight to be aborted before take-off

 

 

Reasons for Noncoverage

The ambulance benefit is a transportation benefit, and without a transport there is no payable service. When multiple ground and/or air ambulance providers/suppliers respond, payment may be made only to the ambulance provider/supplier that actually furnishes the transport. Ambulance providers/suppliers that arrive on the scene but do not furnish a transport are not due payment.

 

No payment may be made for the transport of ambulance staff or other personnel when the patient is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a patient at another hospital).

 

Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or a patient’s home.

 

Items and services which include but are not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are no longer paid separately for ambulance services.

 

 

Post-payment Audit Statement

The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO at any time pursuant to the terms of your provider agreement.

 

Coverage Determination

HHO Duals follows the coverage determinations made by CMS as outlined in either the national coverage determinations (NCD) or the state-specific local carrier determination (LCD).

There is no NCD for Ambulance Services. 

 

At the time of this medical policy development, a state-specific LCD was not available for air ambulance transportation. Additionally, there is a Medicare Benefit Policy Manual on Ambulance Service (Air and Ground). The Medicare Benefit Policy Manual was used to create this policy.

 

General Information

 

Documentation Requirements for non-emergent transport: It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the patient's condition to demonstrate that the ambulance service being furnished meets the medical necessity criteria. Documentation should include a physician’s written order for transport.

Trip record to include:

 • Detailed statement of the condition necessitating the ambulance service

 • Name and address of the certifying physician

 • Name and address of the physician ordering the service if other than the certifying physician

• Point of pick-up (identify place and complete address)

• Destination (identify place and complete address)

 • Number of loaded miles (the number of miles traveled when the patient was in the ambulance) • Cost per mile

 • Mileage charge

 • Minimal or base charge

 • Charge for special items or services with an explanation

• Rationale for the condition (bed confined if applicable) and any further documentation that supports the medical necessity of ambulance transport (i.e. emergency room report)

Documentation Requirements for emergent transport:

 It is the responsibility of the ambulance supplier to furnish complete and accurate documentation of the patient's condition to demonstrate that the ambulance service being furnished meets the medical necessity criteria. Documentation should include a physician’s written order for transport.

Trip record should include:

• Detailed statement of the condition necessitating the ambulance service

 • Name and address of the certifying physician

 • Name and address of the physician ordering the service if other than the certifying physician

 • Point of pick-up (identify place and complete address) • Destination (identify place and complete address)

• Number of loaded miles (the number of miles traveled when the patient was in the ambulance) • Cost per mile

 • Mileage charge • Minimal or base charge

 • Charge for special items or services with an explanation

 • Rationale for the condition (bed confined if applicable) and any further documentation that supports the medical necessity of ambulance transport (i.e. emergency room report).

HHO Duals requires the signature of the patient, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim. Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available upon request. Ambulance services that are not benefits because some other form of transportation is not contraindicated, is an exclusion from the benefits under the statutory definition of that benefit.

An Advance Beneficiary Notice of Noncoverage (ABN) is not needed and should not be used in the following situations:

·       Any denial where the patient could be transported safely by other means.

• Any denial that is based on not meeting an origin or destination requirement.

• A denial for mileage that is beyond the nearest appropriate facility

• A denial where the physician certification statement or accepted alternative (e.g., certified mail) is not obtained.

 • A convenience discharge, e.g., where the patient is an inpatient at one hospital that can care for their needs, but wants to be transferred to a second hospital to be closer to family.

Not obtaining an ABN in these technical denial situations does not prevent the supplier or provider from collecting denied charges from the patient.

Utilization Guidelines Multiple patient transports – a single payment allowance for mileage will be prorated by the number of beneficiaries onboard.

Down coding from air to ground is a denial.

Aspirin alone does not qualify to validate as an indicator that an ALS2 level has been supplied. Oxygen alone, even at high flow rates, does not qualify to validate as an indication that an ALS2 level has been supplied. Administration of IV fluids even with a fluid challenge does not qualify to validate as an indication that an ALS2 level has been supplied.

Nitroglycerin administered as an assist to the patient's own nitroglycerin does not qualify to validate as an indication that an ALS2 level has been supplied. Nitroglycerin administered intravenously from the ambulance stock under a physician's telephonic order, or standing orders does qualify as an indication (as one of three medications) that an ALS2 level has been supplied.

Multiple arrivals - when multiple units respond to a call for services the entity that provides the transport for the patient should be the only provider billing the service.

 

Reimbursement

Participating facilities will be reimbursed by their HHO Duals contract.