Oscar Ambulance Services (CG057) Form

Medical Transportation Services

The Plan members may be eligible for medical transportation services to and/or from a number of different healthcare settings when medical necessity criteria are met. Transport can occur in an emergency or non-emergency setting by ground (e.g., traditional ambulance), air (e.g., helicopter or airplane), or water (e.g., boat). The type of transport depends on the severity and acuity of the member’s conditions as well as the current location of the member and/or nearest medical facility. Trained emergency personnel accompany patients during medical transport. This guideline provides medical necessity criteria for appropriate means of medical transport.

Definitions

• "Emergency" refers to a medical or behavioral condition with acute signs or symptoms and severity such that a prudent layperson possessing an average knowledge of medicine and health reasonably believes in the absence of immediate medical treatment, there may be risk to life (including the unborn child of a pregnant woman) or health in serious jeopardy, risk of serious impairment of bodily function, or risk of serious dysfunction of organ(s) or body part. Some examples of emergency or life-threatening conditions include, but not limited to cardiogenic shock, conditions requiring immediate treatment in a burn center or hyperbaric chamber, intracranial bleeding, acute myocardial infarction, and severe trauma.
• Emergency medical transport can provide:
  • "Basic life support (BLS)" where emergency transport is provided by certified Emergency Medical Technicians (EMTs).
  • "Advanced life support (ALS)" for more critical medical conditions where emergency transport requires the addition of a paramedic.
• "Non-emergency" refers to a medical or behavioral health condition that does not meet the symptom/severity criteria of emergency conditions listed above.
• "Ground transport" refers to traditional ground based transport such as with a motor vehicle over roadways.
• "Air transport" refers to fixed-wing airplane or rotary-wing helicopter transport.
• "Water transport" refers to transport via water craft (e.g., boat).
• "Non-Medical Transport" refers to public and private transportation that does not require trained emergency personnel.

Clinical Indications

Emergency Ground Transport

The Plan considers emergency GROUND medical transport medically necessary when ALL of the following criteria are met:

1. The member has a medical condition meeting the above definition of emergency or that of the member’s plan contracts (e.g., Certificate of Coverage) and any local, state, or federal laws; and
2. Non-emergency medical transport and non-medical transport options would be unsafe or medically contraindicated; and
3. The member is transported to the nearest acute care hospital that can provide the level of care required for the member’s emergent medical condition (in-network when possible); and
4. The transportation has the required equipment and personnel, and meets state and federal regulations for medical transport.

Emergency Air or Water Transport

The Plan considers emergency AIR or WATER medical transport medically necessary when ALL of the following criteria are met:

1. The member meets all criteria above for emergency ground medical transport; and
2. At least ONE of the following is present:
   1. Ground transportation cannot access the member’s location; or
   2. The member’s condition is such that the transport time of any other mode of emergency transportation would reasonably result in threat to life or serious endangerment of health (e.g., due to time-sensitive medical conditions, distance, weather, terrain, natural disaster); or
   3. When the distance is greater than 30 miles, or would take ground transport 30-60mins, and air or water transport provides faster transport to the nearest appropriate facility that can manage the member’s condition.

Ancillary Services

When emergency services meeting the above criteria are provided, ancillary services including the following are also considered medically necessary when required:

• Supplies needed for advanced or basic life support to stabilize the member's condition
• EMT or paramedic services at the scene prior to and during ambulance transportation
• Wait time associated with the ambulance transportation
• Transportation to the hospital providing care (if the initial hospital cannot provided the required level of care, then transportation to the appropriate hospital is considered medically necessary)

Non-Emergency Ground Transport

The Plan considers non-emergency GROUND medical transport medically necessary when ALL of the following criteria are met:

1. The member’s specific condition is such that any other form of transport, including non-medical transport options, is unsafe or medically contraindicated (e.g., member requires ventilation management, bed-confined (i.e., unable to get up from bed without assistance, unable to ambulate, requires special positioning or unable to sit in a wheelchair/chair), etc.,); and
2. When transport is from one facility (all levels of care) to another facility (all levels of care), ONE of the following criteria are met:
   1. A medically necessary service, procedure, or level of care is not available in the facility (e.g., hospital, skilled nursing facility) the member is currently admitted and needs transport to the nearest appropriate facility; or
   2. The member is being transported from an out-of-network care facility to the nearest in-network facility that can manage the member’s condition; and
3. The transportation has the required equipment and personnel, and meets state and federal regulations for medical transport.

Non-Emergency Air or Water Transport

The Plan considers non-emergency AIR or WATER medical transport medically necessary when ALL of the following criteria are met:

1. The member meets all criteria above for non-emergency ground medical transport; and
2. The transport is from one acute/subacute care facility to another acute/subacute care facility;
3. The distance or geography between facilities is such that any other form of transportation (e.g., commercial air) would be unsafe, medically contraindicated, or otherwise not possible, as documented in the medical record or by physician attestation.

Experimental or Investigational / Not Medically Necessary

Transportation services are considered not medically necessary for the following:

• Any medical transport when another form of non-medical transport could have been safely used
• Air ambulance for transport to any location/facility not listed in services above, including, but not limited to physicians offices, nursing facilities, or non-medical locations
• Non-medical transport
• Transportation, of any form, for an excluded or not medically necessary service
• Transportation from a non-licensed operator
• Transportation solely for the convenience of the member, member’s family, or physician
• Transportation to a member’s preferred hospital or facility for personal preference when there is a closer in-network facility that meets the needs of the specific medical condition

Special Situations

The Plan considered emergency transport for deceased members when the member was pronounced dead AFTER a qualifying medical transport has been called or en-route to the healthcare facility as medically necessary. When death occurs before the transport has arrived, transport of the deceased patient to a facility will not be considered medically necessary. When death occurs prior to the call, medical transport services are not medically necessary.