Out-of-State Ambulance Services Form

Page 1 of 3 Out of State Air Ambulance Services Policy Last Reviewed / Revised: 4/11/2025 ALOHACARE Policy Number: MP - 31 Policy Name: Out-of-State Air Ambulance Services Line of Business: QUEST Integration (Medicaid) Place(s) of Service: Inpatient, Outpatient Original Effective Date: August 1, 2025 Review/Revision Dates: N/A Prior Authorization: Required, refer to Section V

Attachment(s): No

I. PURPOSE

This policy outlines the clinical criteria required for coverage of air ambulance transportation from Hawaii to the continental United States. It is designed to ensure that such services are used appropriately in urgent, medically necessary situations where specialized treatment is not available locally. By defining clear eligibility standards, the policy supports timely access to life- saving care while promoting responsible and ethical use of healthcare resources.

II. DESCRIPTION

Critically ill patients in Hawaii may require treatment on the continental United States, and commercial flights are not an option for patients requiring life-supporting equipment and/or a medical support team. Air ambulance services involve the assessment and administration of care to the ill or injured patient by specially trained personnel and the transportation of the patient in specially designed and equipped aircraft within an appropriate, safe, and monitored environment. Air ambulance services from Hawaii to the continental United States are provided by fixed (plane) wing aircraft.

III. POLICY CRITERIA:

Air ambulance services are covered (subject to Limitations and Administrative Guidelines) for individuals receiving care in Hawaii to the continental United States when ALL the following criteria are met (A-F): A. The patient has a high risk of imminent death despite optimal treatment

Page 2 of 3 Out of State Air Ambulance Services Policy Last Reviewed / Revised: 4/11/2025 available in the state of Hawaii. B. The patient has a diagnosis of a treatable medical or behavioral health condition. C. The out-of-state treatment is medically necessary as defined in chapter 432E of the Hawaii Revised Statues, or for QUEST members under Hawaii Administrative Rules (HAR 1700.1-42). D. Treating physician proposed treatment is not available in the state of Hawaii. E. The patient does not have any known contraindications to the out-of-state treatment being sought. F. The patient does not have a short-term expected survival.

IV. LIMITATIONS

A. Air ambulance services within and to and from foreign countries are not covered. B. Air ambulance services are not covered for patients whose condition allows for transport via commercial air transport. C. Air ambulance services are not covered for patients not meeting all criteria in section III.

V. ADMINISTRATIVE GUIDELINES

A. Prior authorization is required. B. Applicable codes:

Code Description A0430 Ambulance service, conventional air services, transport, one way (fixed wing) A0435 Fixed wing air mileage, per statute mile

VI. IMPORTANT REMINDER

The purpose of this Medical Policy is to provide a guide to coverage. This Medical Policy is not intended to dictate to providers how to practice medicine. Nothing in this Medical Policy is intended to discourage or prohibit providing other medical advice or treatment deemed appropriate by the treating physician.

Page 3 of 3 Out of State Air Ambulance Services Policy Last Reviewed / Revised: 4/11/2025 Benefit determinations are subject to applicable member contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

This Medical Policy has been developed through consideration of the medical necessity criteria under Hawaii’s Patients’ Bill of Rights and Responsibilities Act (Hawaii Revised Statutes §432E- 1.4) or for QUEST members under Hawaii Administrative Rules (HAR 1700.1-42), generally accepted standards of medical practice and review of medical literature and government approval status. AlohaCare has determined that services not covered under this Medical Policy will not be medically necessary under Hawaii law in most cases. If a treating physician disagrees with AlohaCare’s determination as to medical necessity in a given case, the physician may request that AlohaCare reconsider the application of the medical necessity criteria to the case at issue in light of any supporting documentation.

VII. REFERENCES AND RESOURCE DOCUMENTS

A. Twenty-Ninth Hawaii State Legislature House of Representatives HB687 H.D. 2. 2017 B. Twenty-Ninth Hawaii State Legislature House of Representative HCR 52 H.D.1 S.D.

1. 2018