Emergency Air Ambulance medical policy effective 11/1/24 Form

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Emergency Air/Water Ambulance Services Medical Guideline

Service: Emergency Air/Water Ambulance Services

PUM 250-0064-2402

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Coverage for Air/Water Ambulance services may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

This medical guideline addresses emergency ambulance transportation for ill or injured patients via air or water. Air ambulance services are provided by rotary wing (helicopters) or fixed wing (airplanes).

Indications of Coverage:

I. Emergency ambulance services are considered medically necessary when the following criteria are met:

A. For air/water ambulance services, ALL of the following criteria must be met:

1. Member has a critical or unstable emergency requiring immediate transport.

2. The transferring hospital or facility or locale does not have adequate facilities to provide the medical services needed by the individual.

3. Transfer is to the closest acute care facility at which the required medical care can be provided.

4. A licensed medical practitioner has been consulted with telephonically/electronically, or air transport has been requested by police or emergency services personnel at the location of the emergency.

   AND AT LEAST ONE OF THE FOLLOWING:

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i. the time to transport by ground would be significantly greater than the time to transport

by air (including prep/mobilization time required by the air ambulance team) and that

time difference is such that the member’s condition could be jeopardized by this delay.

ii. Ground ambulance transport is not feasible, for example, due to remote location or

extreme weather or traffic conditions.

iii. The member requires capabilities or specialty services during transport that can be

provided by the air/water transport team, but not by the ground transport.

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

Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Ambulance services for convenience purposes or personal preference are considered not medically necessary and not a covered benefit. Transport back to the continental United States (repatriation) or transport to a facility preferred by the member/family, when a geographically closer facility is available to provide the needed services, will be considered not a covered benefit and/or not medically necessary.

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

F. Transport beyond the nearest facility equipped to provide the most appropriate care for the member’s condition, as determined by us, will be considered not medically necessary.

Documentation Required:

• Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.

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• Medical record information (including continued need/use if applicable) and medical necessity.
• Ordering physician’s name and phone number (if request is made to Air Ambulance provider). • Physician order and documentation by explaining the reason for Air ambulance transport. • Any additional equipment or personnel needed for transport. • Member’s diagnosis and chief complaint • Member’s current condition (clinical summary) including co-morbidities; current functional limitations; description of members inpatient (IP) stay and progress if applicable. • Where member is traveling from (facility name and contact name/phone number) • Where member is travelling to (facility name and contact name/phone number) • Mileage (one-way) for transport including air mileage and land mileage for transport.
• Correct coding for the item/service that meets all the coding guidelines.

Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

Air/Water ambulance services are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 11/01/24, 03/01/26 Medical Guideline Committee Approval 06/27/24, Q3 2025 Reviewed

06/27/24, Q3 2025 Developed 06/27/24

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Code Description

A0140 NONEMERGENCY TRANSPORTATION AND AIR TRAVEL (PRIVATE OR COMMERCIAL) INTRA-OR INTERSTATE
A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT ONE WAY (ROTARY WING) A0435 FIXED WING AIR MILEAGE, PER STATUTE MILE A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE S9960 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, NONEMERGENCY TRANSPORT, ONE WAY (FIXED WING)
S9961 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICE, NONEMERGENT TRANSPORT, ONE WAY (ROTARY WING)