Medical Policy: 10.01.17
Original Effective Date: June 2012
Reviewed: April 2015
Revised: May 2014
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Aeromedical transport services utilizing specially designed and equipped airplanes or helicopters are important in providing rapid emergency medical care and transport of ill or injured patients. These air medical services may be involved in a primary response (transporting a patient from the scene to a nearby receiving facility) or a secondary response (interfacility transport due to the patient's need for a higher level of care).
Prior approval is required for non-emergent air* transportation. Submit a prior approval now .
*Emergent medical care would be considered medically necessary services for an illness or injury that would result in further disability or death if professional attention is not delivered immediately. If the air transportation does not meet this definition of emergent care, then the air transportation services would be considered as non-emergent.
Professional air ambulance transportation services may be considered a covered benefit when ALL of the following are met:
- Transport service is to the nearest hospital or nursing facility with adequate facilities to treat the medical condition; and
- The services required to treat the illness or injury are not available in the facility where currently receiving care; and
- There is no other method of transportation that is appropriate and meets ALL of the following:
- The air ambulance has the necessary patient care equipment and supplies to meet the patient's needs;
- The patient's medical condition requires immediate and rapid ambulance transport that could not have been provided by ground ambulance or the point of pick up is inaccessible by land vehicle;
- Great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment;
- The patient's condition is such that the time needed to transport a patient by land poses a threat to the patient's health.
Professional air ambulance transportation services for an interfacility transport from a hospital capable of treating an individual performed primarily for the convenience of the patient or patient’s family, physician or other health care provider would be considered a non-covered benefit.
Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or diagnosis codes.
- A0430 Ambulance service, conventional air services, transport, one way (fixed wing)
- A0431 Ambulance service, conventional air services, transport, one way (rotary wing)
- A0435 Fixed wing air mileage, per statute mile
- A0436 Rotary wing air mileage, per statute mile
- S9960 Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)
- S9961 Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)
- Revenue Code 545
- Medicare Benefit Policy Manual. Chapter 10-Ambulance Services (Rev. 133, 10-22-10). Available at https://www.cms.gov/manuals/Downloads/bp102c10.pdf. (Accessed on 3/28/12)
- Thomson DP, Thomas SH; 2002-2003 Air Medical Services Committee of the National Association of EMS Physicians. Guidelines for Air Medical Dispatch. Prehosp Emerg Care. 2007 (2):265-271.
- American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed June, 2008). Available at http://www.acep.org/practres.aspx?id=29078. (Accessed on 3/28/12)
Date Reason Action
June 2012 New policy
May 2013 Annual review Policy renewed
May 2014 Annual review Policy revised
April 2015 Annual review Policy renewed
Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2012 American Medical Association. All Rights Reserved.