This document addresses the use of air or water ambulance services. An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. 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-05 Ambulance Services: Ground; Emergent
• CG-ANC-06 Ambulance Services: Ground; Non-Emergent
• CG-ANC-07 Inpatient Interfacility Transfers

Clinical Indications

Medically Necessary:

The use of air and water ambulance services is considered medically necessary when all the following criteria are 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 form of transportation other than by ambulance would be medically contraindicated; and
3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
4. There is a medical condition that is life threatening or first responders deem to be life threatening, including, but not limited to, the following:
   1. Intracranial bleeding; or
   2. Cardiogenic shock; or
   3. Major burns requiring immediate treatment in a Burn Center; or
   4. Conditions requiring immediate treatment in a Hyperbaric Oxygen Unit; or
   5. Multiple severe injuries; or
   6. Transplants; or
   7. Limb-threatening trauma; or
   8. High risk pregnancy; or
   9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

*Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

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

The use of air and water ambulance services to transport an individual from one hospital to another requires that:

1. The above criteria must be met, and
2. The first hospital does not have the required services and facilities to treat the individual.

The use of air and water ambulance services for deceased individuals is considered medically necessary when the above criteria are 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. In these circumstances the response to call is considered medically necessary.

Not Medically Necessary:

All other uses of air and water ambulance services are considered not medically necessary, including, but not limited to, the following:

1. Transfers from one hospital to another if above criteria not met; or
2. Transfers 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
3. When land transportation is available and the time required to transport the individual by land does not endanger the individual’s life or health; or
4. Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician’s office or the individual’s home; or
5. The services are for a transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead at the scene.

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