This document addresses the use of ground ambulances in emergency situations. 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-04 Ambulance Services: Air and Water
• CG-ANC-06 Ambulance Services: Ground; Non-Emergent
• CG-ANC-07 Inpatient Interfacility Transfers

Clinical Indications

Medically Necessary:

The use of emergency ground 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. Either of the following circumstances exists:
   1. Transportation from the scene of a life-threatening accident or emergency to the nearest* hospital or physician’s office with appropriate facilities for treatment of an individual’s illness or injury is required; or
   2. 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 emergent 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.

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

Emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above 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.

Ambulance providers are required to respond to all emergency calls, but occasionally after assessment, transport is declined by the individual. In such cases ambulance services would be considered medically necessary.

Not Medically Necessary:

The use of emergency ground ambulance services is considered not medically necessary when:

1. The criteria and circumstances above have not been met; or
2. The services are primarily for the convenience of the individual or the individual’s family or physician; or
3. 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.