Non-Emergent Transportation Form

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Non-Emergent Transportation Medical Policy Policy Effective: 10/1/2025 Policy Number: UM978POL

Approval Date: 9/9/2025

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Non-emergency, medically necessary transportation may be for scheduled or non-scheduled medical treatment. Such transportation requires prior authorization approved by the plan and must be noted in an approved authorization.

 Line of Business

Commercial:
Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:
HNE does not cover non-urgent transportation because these services are included in the Medicaid non- emergency Medical Transportation (NEMT) Benefit which is directly covered by MassHealth.

Medicare:
Health New England follows guidance from the Centers for Medicare and Medicaid Services (CMS) to determine coverage of non-emergent transportation. This guidance is found at: https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/bp102c10.pdf

Policy
Commercial and Medicare: The following origin/destination does not require prior authorization for transportation under 150 miles:
• Hospital to Hospital
• Hospital to Acute Rehabilitation or Skilled Nursing Facility • Acute Rehabilitation or Skilled Nursing Facility to Hospital

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Commercial: NON-EMERGENCY GROUND TRANSPORTATION: I. Non-emergency ground ambulance services are considered medically necessary when the following Criteria is met.

a. The ambulance must have the necessary equipment and supplies to address the needs of the individual; AND

b. The transportation is for the transport to and/or from medically necessary care; AND

c. The member’s medical condition prohibits safe transportation by other forms of transportation due to one or more of the following:

i. The member is bed confined. before and after transport (This is defined as: unable to get out of bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair); OR

ii. Other means of transportation are contraindicated for one or more of the following medical reasons.

1. The member cannot safely sit upright while seated in a wheelchair; or
2. The member can tolerate a wheelchair but is medically unstable; or
3. The member requires oxygen and oxygen saturation level monitoring, in the absence of a portable oxygen system, to treat hypoxemia, syncope, airway obstruction and/or chest pain; or
4. The member requires physical restraint during transportation or is at risk for harming themselves or others; or
5. The member has a specific physical condition (e.g., body cast, spica cast) limitation that prevents safe transfer in other mode of transportation; or

6. The member requires continued medical isolation precautions for an active infectious process; OR

   iii. The member requires oxygen and oxygen saturation level monitoring, in the absence of a portable oxygen system, to treat hypoxemia, syncope, airway obstruction and/or chest pain, OR

   iv. The member requires skilled/trained monitoring during transport for one of the following:

7. The Member is comatose.
8. The Member requires airway monitoring.
9. The Member requires cardiac monitoring.
10. The Member is dependent on a ventilator

11. The member is dependent on other enabling machines and devices.

    II. Coverage of a wheelchair van may be approved when the transportation is for the transport to and/or from medically necessary care AND

    a. The member is unable to ambulate with or without assistance, and with or without an assistive device AND

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b. The member is unable to safely transfer from a wheelchair to a private vehicle, with or without assistance AND

c. The member requires medical transportation whenever he/she accesses the community for any purpose and cannot be safely transported by private car or taxi NON-EMERGENT AIR AMBULANCE TRANSPORTATION I. Non-emergency air ambulance transport requests are considered medically necessary when all of the following criteria are met:

A. The service is medically required due to the patient’s clinical status; AND

B. There is documented evidence in the medical record that the patient is not reasonably able to transport by other means due to a medical condition, and the need for immediate or rapid transport is identified; AND

C. The non-emergency air ambulance transportation is directly related to inpatient hospital acute care; AND

D. The inpatient acute care facility where the patient is currently admitted is not equipped to adequately treat the condition, and/or the patient requires transport to the inpatient acute care facility to receive a prior approved transplant; AND

E. The travel time for transport by alternate means (i.e. basic or advanced life support ground or sea ambulance) would result in a clinically significant delay in the patient receiving the required care, such as significant travel distances, natural disasters, extreme weather conditions or other barriers to transfer, which could potentially “jeopardize the patient’s health, life or ability to regain maximum function. Not Medically Necessary: Non-emergency ground and air ambulance services are considered not medically necessary when the above criteria are not met and for all other indications.

Coding Guidance

Code
Description
PA A0130 Nonemergency transportation: wheelchair van (Not covered by Medicare) Yes A0425 Ground mileage, per statute mile No A0426 Ambulance service, advanced life support, non-emergency transport, level 1 (ALS 1) Yes A0428 Ambulance service, basic life support, non-emergency transport (BLS) Yes A0430 Ambulance service, conventional air services, transport, one way (fixed wing) Yes A0431 Ambulance service, conventional air services, transport, one way (rotary wing) Yes A0435 Fixed wing air mileage, per statute mile Yes See Policy section for transports that do not require PA

CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document

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and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Centers for Medicare & Medicaid Service (10-1-20 Edition) 42 Code of Federal Regulations (CFR) 410.4. https://www.govinfo.gov/content/pkg/CFR-2020-title42-vol2/pdf/CFR-2020-title42-vol2- part410.pdf#page=33.

Centers for Medicare & Medicaid Services. (2018, April 13). Medicare Benefit Policy Manual. Ambulance Services. Retrieved from CMS.gov: https://www.cms.gov/Regulations- andGuidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed February 2023

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 11/2024 Initial policy date 8/2024 Reviewed with no changes to criteria.
Entered A0130 to the coding table.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be

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mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.