Humana Commercial Clinical Policy

Humana Air Ambulance Form


Effective Date

04/27/2023

Last Reviewed

NA

Original Document

  Reference



Description

Air ambulance is a specially equipped aircraft capable of providing medically necessary services and supplies to transport an ill or injured individual to the nearest appropriate acute facility for treatment. Transportation can occur via helicopter or fixed wing airplanes. Air ambulances may be necessary when the individual’s condition requires rapid transport to a treatment facility and great distance or obstacles, such as heavy traffic or inaccessibility by ground ambulance, impede rapid delivery to the nearest appropriate treatment facility.

Helicopters (rotary wing air ambulances) are used more often in densely populated areas and can provide advanced life support (ALS) to large rural areas that are unable to sustain independent ALS units.

Airplanes (fixed wing air ambulances) provide faster, smoother, quieter and more spacious transportation. Fixed wing air ambulances require a runway and are not capable of direct scene access but are preferred when the referring medical facility is of greater distance.

Coverage Determination

Any state mandates for air ambulance take precedence over this medical coverage policy.

Humana members may be eligible under the Plan for air ambulance when the following criteria are met:

  • Individual’s medical condition is critical and/or has unstable vital signs, cardiac or respiratory status including, but not limited to, one of the following conditions:
    • Acute intracranial bleeding requiring neurosurgical intervention; OR
    • Acute myocardial infarction requiring timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy); OR
    • Cardiogenic shock; OR
    • Conditions requiring immediate treatment in a hyperbaric oxygen unit; OR
    • High risk pregnancy with immediate risk to the mother or fetus; OR
    • Limb-threatening trauma; OR
    • Major burns requiring immediate treatment in a burn center; OR
    • Multiple severe injuries; OR
    • Newborn infant requiring treatment for complications of premature birth, congenital birth defects, illness or injury; OR
    • Transplant with ALL of the following:
  • Individual is approved for transplant; AND
  • Facility is authorized to perform the transplant for the individual; AND
  • Proposed transplant is urgent and time critical; AND
  • Urgent circumstances prevent prearrangement for an alternative mode of transportation; AND
  • All of the following:
    • Transfer is to an acute care medical facility; AND
    • Transferring hospital does not have adequate facilities to provide the medical services needed by the individual; AND
    • Ground ambulance would take 30-60 minutes or more to transport an individual whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the individual's illness/injury; AND
    • Inaccessibility to ground ambulance transport (eg, traffic or weather conditions) or extended length of time required to transport the individual via ground ambulance transportation could endanger the individual

Mileage associated with an air ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility.

Note: The criteria for air ambulance are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for air ambulance for any indications other than those listed above including, but may not be limited to;

  • Ground ambulance is available and the time required to transport the individual by land does not endanger the individual's life or health; OR
  • Transfer from a hospital capable of treating an individual to another hospital primarily for the convenience of the individual or the individual's family or physician; OR
  • Transportation to a facility that is not an acute care medical facility

All other indications are considered not medically necessary as defined in the member's individual certificate. Please refer to the member's individual certificate for the specific definition.

Mileage in excess of the distance from the trip origin to the nearest appropriate facility is considered not medically necessary. Please refer to the member's individual certificate for the specific definition.

Additional Information

Additional information about fixed wing or helicopter air ambulance service may be found from the following websites:

  • Background
    • National Library of Medicine
References
  1. American College of Emergency Physicians (ACEP). Appropriate and safe utilization of helicopter emergency medical services. https://www.acep.org. Published April 2011. Updated September 2018. Accessed March 20, 2023.
  2. American College of Obstetricians and Gynecologists (ACOG). Obstetric Care Consensus. Levels of maternal care. https://www.acog.org. Published August 2019. Accessed March 20, 2023.
  3. American College of Surgeons (ACS). ACS TQIP best practices in the management of orthopaedic trauma. https://www.facs.org. Published November 2015. Accessed March 29, 2023.
  4. Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual Chapter 10- Ambulance Services. https://www.cms.gov. Published April 13, 2018. Accessed March 28, 2023.
  5. ClinicalKey. Wright J, King S. Emergency medical services for children. In: Kliegman R, St. Geme J, Blum N, et al. Nelson Textbook of Pediatrics. Elsevier; 2020:515-526. https://www.clinicalkey.com. Accessed March 29, 2023.
  6. Romito J, Alexander S. Transport mode: issues, timing, safety, selection criteria, considerations, and options. Guidelines for Air & Ground Transport of Neonatal and Pediatric Patients Manual. 2015:179-214.
  7. Thomson D, Thomas S. American College of Emergency Physicians and National Association of EMS Physicians guidelines for air medical dispatch. Prehosp Emerg Care. 2003;7(2):265-271. https://www.tandfonline.com. Accessed March 29, 2023.
  8. UpToDate, Inc. Inter-facility maternal transport. https://www.uptodate.com. Updated February 2023. Accessed March 30, 2023.
  9. UpToDate, Inc. Prehospital pediatric and emergency medical services (EMS). https://www.uptodate.com. Updated February 2023. Accessed March 29, 2023.
  10. UpToDate, Inc. Transport of surgical patients. https://www.uptodate.com. Updated February 2023. Accessed March 30, 2023.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Air Ambulance Effective Date:

04/27/2023

Revision Date:

04/27/2023

Review Date:

04/27/2023

Policy Number:

HUM-0577-002

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Want to learn more?