*** This policy was implemented in the absence of National Coverage Determinations (NCD) or Local Coverage Determinations (LCD) coverage criteria. This policy applies to all Blue Medicare HMO, Blue Medicare PPO, Healthy Blue + MedicareSM (HMO-POS D-SNP), Blue Medicare Rx members, and members of any third-party Medicare plans supported by Blue Cross NC through administrative or operational services. ***

Description of Procedure or Service

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions during the transportation of ill or injured members. The member’s clinical condition is such that the use of any other method of transportation would be contraindicated.

The vehicle must be designed and equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting individuals with acute medical conditions.

Ambulance and medical transport services may involve ground, air, or sea transport in both emergency and non-emergency situations. Air or ground ambulance service is covered to the nearest medical facility capable of providing emergency care for an emergency medical condition.  

Summary Statement

Coverage will be provided for ambulance and medical transport services when it is determined to be medically necessary, as outlined in the below guidelines and medical criteria.

Benefit Application

Please refer to the member’s individual Evidence of Coverage (EOC) for benefits.

Coverage decisions are made in accordance with:

• The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations;
• General coverage guidelines included in Original Medicare manuals unless superseded by operational policy letters or regulations; and
• Written coverage decisions of local Medicare carriers and intermediaries with jurisdiction for claims in the geographic area in which services are covered.

Benefit payments are subject to contractual obligations of the Plan. If there is a conflict between the general policy guidelines contained in the Medical Coverage Policy Manual and the terms of the member’s particular Evidence of Coverage (EOC), the EOC always governs the determination of benefits.

Indications for Coverage

1. Any other means of transportation would be contraindicated because:
   1. The member is bed-confined (unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair) and the member’s medical condition is such that other methods of transportation are contraindicated, meaning any other means of transportation would endanger the members health or
   2. The member’s medical condition would be jeopardized by transportation in the absence of medically trained personnel.
      
      AND
       
2. The member is transported to specific destinations:
   1. To a hospital, critical access hospital (CAH) or skilled nursing facility (SNF) from any point of origin; or
   2. To the member’s home from a hospital or SNF; or
   3. Round-trip from a SNF to the nearest supplier of medically necessary services not available at the SNF where the member is a resident, and the cost would be prohibitive to bring the service to the member; or
   4. Round-trip from the member’s home or SNF to the nearest facility that furnishes renal dialysis for a member receiving renal dialysis for treatment of ESRD.
   5. Physician’s office if enroute to a Medicare approved destination; but only if the member is in dire need for professional attention, and immediately thereafter, the ambulance continues to a covered destination.
      
      AND
       
3. Transportation is certified as medically necessary by a physician directly responsible for the beneficiary's care

The member must meet ALL of the criteria below for NON-EMERGENT AIR ambulance (Rotary Wing- aircraft (helicopter) or fixed-wing aircraft (airplane) transportation:

1. The members medical condition is such that transportation by either basic or advanced life support land ambulance is not appropriate, The members medical condition is such that transportation by either basic or advanced life support land ambulance is not appropriate, AND
2. The member’s medical condition requires immediate and rapid ambulance transportation that could not have been provided by land ambulance and one of the following conditions applies:
   1. The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States), or
   2. Great distances, limited time frames, or other obstacles (for example, heavy traffic) are involved in getting the member to the nearest hospital with appropriate facilities, or
   3. The member’s condition is such that the time needed to transport a member by land to the nearest appropriate medical facility poses a threat to the member’s health.

Serious health conditions that require immediate air transport may include, but are not limited to:

• Intracranial bleeding- requiring neurosurgical intervention;
• Cardiogenic shock;
• Burns requiring treatment at a Burn Center;
• Conditions such as carbon monoxide poisoning requiring treatment in a Hyperbaric Oxygen Unit;
• Multiple severe injuries;
• Life-threatening trauma.

Note: Ground or Air transportation from facility to facility requires prior approval unless it is urgent/emergent.  

When Coverage Wil Not be Approved

• When medical attention is not required, routine transportation is not covered.
• Ambulance transportation to/from a physician’s office for a routine office visit is not covered
• Ambulance transportation (ground or air) if the member was pronounced deceased prior to the ambulance being called is not covered. The pronouncement must be made by a person who is legally authorized to make such a pronouncement, usually a physician.
• Transportation from one (1) institution to another for the member’s or family’s convenience is not covered. If any means of transportation other than an ambulance could be utilized without endangering the member’s health, whether or not this transportation is available, ambulance service is not covered.
• Transportation for the purpose of receiving an excluded service (such as, but not limited to, a routine dental examination) is not covered.
• 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 beneficiary’s home.

Billing/ Coding/Physician Documentation Information

This policy may apply to the following codes. Inclusion of a code in the section does not guarantee reimbursement.

Applicable Codes: A0425, A0426, A0427, A0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436.

All ambulance transport codes, and mileage codes must be reported with both the corresponding origin and destination modifiers.

The Plan may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included. 

Special Notes

• Examples of non-emergent transportation include transportation from:
  1. Acute care to a lesser level of covered care must meet MN.
  2. A covered SNF to a contracting physician’s office to obtain medically necessary diagnostic or therapeutics services not available at the SNF.
  3. A non-contracting facility to a contracting facility, only when services are not available at the non-contracting facility
  4. A contracting facility to a contracting facility for testing or therapy that is not available at the first facility.
  5. Bed-confinement is neither sufficient nor is it necessary to determine coverage for Medicare benefits. Documentation of the current medical status is required. It is simply one element of the member's condition that may be considered in the determination of whether means of transport other than an ambulance were contraindicated.
• When a Member is in a SNF stay, in order to review whether transport is covered under Part A (Consolidated Billing) or Part B (Separately Billable) benefits please see Chapter 10 section 10.3.3 of the Medicare Benefit Policy Manual, and Chapter 15, of the Medicare Claims Processing Manual.
• Medicare allows payment for an air ambulance service when the air ambulance takes off to pick up a Medicare beneficiary, but the beneficiary 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. 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 or in cases where 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
• Transportation for the purpose of receiving a service that could have been safely and effectively provided at the point of origin, then the transport is not covered even if the member could only have gone by ambulance.
• Transportation and Lodging Expenses Related to Transplants: When the Plan pre-authorizes a member to receive transplant services at a facility located at a distant location (farther away than the normal community pattern of care for the type of transplant), the Plan will cover reasonable expenses for transportation to and lodging at the distant location for the member and a companion.
  1. Transportation and Lodging will only be approved during the transplant period. The transplant period is defined as starting 5 days before the transplant and ends one year after surgery. The maximum amount payable for allowed transportation and lodging services, which includes costs for both you and your companion, related to an approved covered transplant is $10,000 per transplant.
  2. When transplant services are provided by a facility that is within the normal community pattern of care, transportation and lodging expenses are not covered by the Plan. Lodging must be approved in advance and arranged through the transplant coordinator at the transplant center or the Plan.

References

1. Medicare Benefit Policy Manual, Chapter 10 – Ambulance Services; Effective date, 7/11/2014, Accessed via Medicare Benefit Policy Manual (cms.gov). Viewed on 08/11/2025.
2. Medicare Claims Processing Manual, Chapter 15 – Ambulance; Effective date, 10/7/2014, Accessed via Medicare Claims Processing Manual (cms.gov). Viewed on 08/11/2025
3. Blue Cross NC Commercial Policy – Ambulance and Medical Transport Services; effective date 4/1981; accessed via Ambulance and Medical Transport Services | Providers | Blue Cross NC viewed on 8/11/2025
4. Medicare Local Coverage Determination for Ambulance Services- Palmetto GBA Part A/B (L34549); Effective date: 10/01/2015. Accessed via LCD – Ambulance Services (L34549) (cms.gov) viewed on 02/26/2024.—retired on 8/31/2024
5. Medicare Local Coverage Article for Billing and Coding: Ambulance Services—Palmetto GBA Part A/B (A56468): Effective date: 04/04/2019. Accessed via Article - Billing and Coding: Ambulance Services (A56468) (cms.gov) on 02/26/2024.—retired on 8/31/2024

Policy Implementation/Update Information

Revision Dates: March 23, 1998; September 25, 2001; June 22, 2005 (Policy renamed “Ambulance Transportation” on May 18, 2005: Previous title “Non-emergent Transportation”)

Revision Date: May 2007: Formatting changes; Added bullet “c” under #2 for air ambulance transport; Added transportation for excluded services are not covered under When coverage will not be approved.

Revision Date: September 2009: No changes proposed to the review criteria. Formatting and minor wording changes only.

Revision Date: March 2012: Added language under indications for coverage under 1A to match LCD regarding to clarify what constitutes bed-confined requiring transportation; added language to address when transportation to physician’s office is eligible for coverage.

Revision Date: February 20, 2013; Edited language to mirror NCD and LCD. Deleted Codes A0382, A0384, A0392, A0394, A0396, A0398, A0420, A0422, A0999.

Revision Date: March 18, 2015; No updates to coverage criteria, no revisions to policy. October 29, 2015, updated LCD due to ICD-10 update only.

Revision Date: March 15, 2017; Annual review. No updates to coverage criteria, no revisions to policy.

Revision Date: June 20, 2018; Staff Clarification; Added “Transportation for the purpose of receiving a service that could have been safely and effectively provided at the point of origin, then the transport is not covered even if the member could only have gone by ambulance.” to ”When Coverage Will Not Be Approved” per staff request. Added Special Note: “When a Member is in a SNF stay, in order to review whether transport is covered under Part A (Consolidated Billing) or Part B (Separately Billable) benefits please see Chapter 10 of the Medicare Benefit Policy Manual, and Chapter 15, of the Medicare Claims Processing Manual.”

Revision Date: June 17, 2020: Annual Review. No CMS Updates. Minor Revisions Only.

Revision Date: July 20, 2022: Annual Review. No CMS Updates. Minor Revisions Only.

Revision Date: October 18, 2023: Annual Review. No CMS Updates. Minor Revisions Only. Added an additional reference.

Revision Date: November 16, 2023: Policy converted to a Summary of Coverage Criteria to align with the 2024 CMS Final Rule.

Revision Date: March 22, 2024: Annual Review. No CMS Updates. Minor Revisions only to reflect LCD.

Revision Date: September 19, 2024: CMS Update: LCD L34549 and LCA A56468 were retired on 8/31/2024. LCD and LCA marked as old references in the reference section. Verbiage added to reflect CMS Manuals.

Revision Date: December 19, 2024: No CMS Updates. Verbiage added under “Special Notes” to reflect verbiage from the new Transportation and Lodging Related to Transplants policy.

Revision Date: August 21, 2025; Converted to a Policy in the absence of an NCD or LCD. No CMS Guidance updates. Added additional language regarding the criteria for a fixed or rotary winged ambulance.

Approval Dates

Medical Coverage Policy Committee: August 21, 2025
Policy Owner: Amy Russo, LPN Medical Policy Coordinator