This document addresses the use of ground ambulances in non-emergency situations only. Wheelchair vans or other such vehicles are not equipped as ambulances and are not addressed in this document.

Note: Please see the following related documents for additional information.

• CG-ANC-04 Ambulance Services: Air and Water
• CG-ANC-05 Ambulance Services: Ground; Emergent

Clinical Indications

Medically Necessary:

Non-emergency ground ambulance services are considered medically necessary when the following criteria are met (A, B, and C must be met):

1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
2. The individual’s condition must be such that any other form of transportation would be medically contraindicated (for example bed-confined [unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair]); and
3. Either of the following circumstances exists:
   1. Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides; or
   2. The requested transfer is from an acute care facility to an individual’s home or a skilled nursing facility.

Mileage associated with the ground ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate location.

Non-emergency ground ambulance services are considered medically necessary if the ground ambulance provider responds to a call and provides medically necessary treatment, but the ambulance transport is not completed.

Non-emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above have been met and when either of the following is present:

1. The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up.

Not Medically Necessary:

Non-emergency ground ambulance services are considered not medically necessary when the above criteria are not met and for all other indications.

Mileage in excess of the distance from the trip origin to the nearest appropriate location is considered not medically necessary.