Ambulance: Air and Water Transport Form

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|04|2007 POLICY LAST REVIEWED: 07|02|2025 OVERVIEW This policy documents medical criteria requirements for coverage of ambulance air and water transportation. MEDICAL CRITERIA Air or water ambulance is considered medically necessary when: • The time needed to transport a patient by land or the instability of transportation by land, poses a threat to the patient’s condition or survival; or • The proper equipment needed to treat the patient is not available from a ground ambulance; and • The patient must be transported for treatment to the nearest appropriate hospital that is capable of providing a level of care for the patient’s illness and that has available the type of physician or physician specialist needed to treat the patient’s condition; and • The patient needs to be transferred from one hospital to the nearest appropriate hospital, if the transferring hospital does not have the appropriate facilities to provide the medical services the patient needs (such as a trauma unit, burn unit, or cardiac care unit). PRIOR AUTHORIZATION Prior authorization review is required for Medicare and Advantage Plans and recommended for Commercial products. Note: As air and water ambulance service is normally of an urgent or emergent nature, a retrospective review of documentation will be performed prior to payment authorization.
POLICY STATEMENT Medicare Advantage Plans and Commercial Products: Air or water ambulance services are covered when the medical criteria are met. The allowance for the air or water ambulance includes the services rendered by an emergency medical technician or paramedic, drugs, supplies and cardiac monitoring. Services are covered up to the maximum benefit limit and level of coverage according to the member's contract. Non-covered Conditions: Medicare Advantage Plans and Commercial Products: • Transport to a facility that is not an acute care hospital. • Transportation for the purpose of continuity of care only (for example, when the member wishes to be seen by his or her own physician specialist, who may not be at the nearest appropriate hospital, and not a specialist located at the nearest appropriate hospital.) • Return air, water, or ground transportation home. • Transport on commercial or charter flights that are not certified air ambulances. Medical Coverage Policy | Ambulance: Air and Water Transport

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

• Repatriation and medical evacuation services for transportation back to the United States from another country.

COVERAGE Benefits may vary between groups/contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for the applicable “Ambulance services” benefits/coverage.

BACKGROUND Air ambulance service means transportation by a helicopter or fixed wing plane. The aircraft must be a certified ambulance. The crew, maintenance support crew and aircraft must meet the certification requirements and hold a certificate for air ambulance operators under Part 135 of the Federal Aviation Administration (FAA) regulations.

Water ambulance means transportation by a boat. The boat must be specially designed and equipped for transporting the sick or injured. It must also have such other safety and lifesaving equipment per state or local regulation.

CODING Medicare Advantage Plans and Commercial Products These HCPCS codes for air ambulance transportation will be retrospectively reviewed for all BCBSRI products: 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 (if mileage is over one mile)
A0436 Rotary wing air mileage, per statute mile (if mileage is over one mile)

Water ambulance transportation services are covered for all BCBSRI products and will be processed according to the unlisted review process:
A0999 Unlisted ambulance service

The following code will follow the unlisted code review process when used for fixed or rotary winged emergency travel for all BCBSRI products:
A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged)

RELATED POLICIES Not applicable

PUBLISHED Provider Update, September 2025 Provider Update, March 2024, May 2024 Provider Update, April 2023 Provider Update, April 2022 Provider Update, November 2021

REFERENCES

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services-10.4-Air Ambulance Services.
2. Centers for Medicare and Medicaid Services. Medicare Claims Processing Manual Chapter 15 – Ambulance.
3. Centers for Medicare and Medicaid Services. Your Medicare Benefits: This official government guide has important information about the following: The services and supplies original Medicare covers. p. 47. CMS Product No. 10116.

500 EXCHANGE STREET, P ROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

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This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber a greement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS