Medical Policy: 10.01.17 

Original Effective Date: June 2012 

Reviewed: March 2020 

Revised: March 2019 

 

Notice:

This policy contains information which is clinical in nature. The policy is not medical advice. The information in this policy is used by Wellmark to make determinations whether medical treatment is covered under the terms of a Wellmark member's health benefit plan. Physicians and other health care providers are responsible for medical advice and treatment. If you have specific health care needs, you should consult an appropriate health care professional. If you would like to request an accessible version of this document, please contact customer service at 800-524-9242.

 

Benefit Application:

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.

 

Description:

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).

 

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 person’s life or health. As a general guideline, when it would take a ground ambulance 30-60+ minutes or more to transport a person whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the person’s illness/injury would be a likely candidate for air ambulance. Your condition must be such that the time needed to transport you by land poses a threat to your health.

 

Prior Approval:

Prior approval is required.

 

*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.

 

Policy:

Professional emergency air ambulance transportation services may be considered a covered benefit when ALL of the following are met:

  • Transport service is to the nearest hospital 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
  • The patient’s medical condition requires immediate and rapid air ambulance transport that cannot be provided by a ground ambulance 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, excessive time frames (generally more than 30-60 minutes), 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.

 

Non-Covered Benefit

Professional non-emergency air ambulance transportation services for an interfacility transport from a facility 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 0545

 

Selected References:

  • Medicare Benefit Policy Manual. Chapter 10-Ambulance Services (Rev. 133, 10-22-10). (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).
  • Medicare Coverage of Ambulance Services

 

Policy History:

  • March 2020- Annual Review, Policy Renewed
  • March 2019 - Annual Review, Policy Renewed
  • March 2018 - Annual Review, Policy Renewed
  • December 2017 - Interim Review, Policy revised
  • March 2017 - Annual Review, Policy Renewed
  • March 2016 - Annual Review, Policy Renewed
  • April 2015 - Annual Review, Policy Renewed
  • May 2014 - Annual Review, Policy Revised
  • May 2013 - Annual Review, Policy Renewed
  • June 2012 - New Policy

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.

 

*CPT® is a registered trademark of the American Medical Association.