Point32 Medical Transportation Form

Harvard Pilgrim HealthCare
Medical Policy

Medical Transportation

Subject: Medical Transportation

Authorization:
Prior authorization is required for ALL non-emergent fixed-wing air and ground transportation provided to members enrolled in commercial and Marketplace/Exchange (HMO, POS and PPO) products.

• Prior authorization is not required for emergency transportation that is reasonable and medically necessary to ensure the member’s safe transport to the nearest medical provider capable of furnishing covered services.
• Prior authorization is not required for any transportation via wheelchair van.
• Prior authorization is not required when both the origin and destination modifiers are H. See the modifier grid below for accepted types of facilities for this modifier.
• Prior authorization is not required for H-N modifiers. See the modifier grid below for accepted types of facilities for this modifier.

Harvard Pilgrim Health Care (HPHC) does not review, or deny coverage for, services provided to a member in a medical emergency, but does accept post-service notification (confirming the emergent nature of the situation) to facilitate appropriate claims payment for EMERGENT fixed wing air transport.

Policy and Coverage Criteria:

GENERAL CRITERIA:

Harvard Pilgrim Health Care (HPHC) considers medical air ambulance and ground transportation as reasonable and medically necessary when documentation confirms transport is to ensure a member’s safe transport to/from hospitals (including behavioral health hospitals) and other covered facilities (e.g., subacute nursing facilities). The determination of medical necessity is based on medical information received at the time of the request for the service

• Covered services, including emergent and non-emergent air and ground transportation, must be reasonable and medically necessary (based on the member's condition), and rendered by appropriately licensed providers who are certified in accordance with relevant state and local laws. Stair safety concerns, or the member's inability to negotiate stairs, in the absence of another medical condition that meets medical necessity criteria, do not satisfy medical necessity requirements.
• The member's health condition at the time of transport must be such that the use of any other method of transportation (e.g., taxicab, private car) would be medically contraindicated or endanger the member's medical condition, and the member must require the presence of medical personnel who are certified and/or licensed to provide monitoring and/or interventional medical services.

Harvard Pilgrim Health Care (HPHC) does not cover non-emergent air or ground transportation to/from origins or destinations not designated by policy criteria, even if medical necessity criteria are otherwise met.

Examples of medical conditions that satisfy Harvard Pilgrim medical necessity requirements include:

• Member is bed-confined before and after transport (may include members who are bed-confined due to morbid obesity), or must remain in a supine or prone position (i.e., Z74.01).
• Member is unable to sit in a chair or wheelchair for the duration of the transport.
• Member requires physical restraint during transportation (i.e., Z78.1).
• Member is dependent on other enabling machines and devices (i.e., Z99.89).

HPHC Medical Policy

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Medical Transportation
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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g.

Please reference appropriate member materials (e.g., Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

• Member is in a body cast or spica cast or must remain immobile because of a fracture that has not been set, or the possibility of a fracture (e.g., hip fracture).
• Member has lower extremity contractures of such degree that they prohibit sitting in a wheelchair (severe fixed contractures at or proximal to the knee).
• Member has a health condition that would be exacerbated by transport in a vehicle other than an ambulance.
• Member must be moved by stretcher because of a specific physical condition or limitation. (NOTE: Per the American Academy of Orthopedic Surgeons, most individuals s/p hip replacement may sit in a chair slightly higher than the average seat (e.g., wheelchair), and most individuals s/p knee replacement should be able to bend their knee approximately 90 degrees at the time of discharge. In most cases, these conditions alone do not satisfy the medical necessity requirement).
• Member requires maintenance of medical isolation precautions for an active infectious process.
• Member requires a skilled service during transport (e.g., ventilator care, nursing), or oxygen therapy that cannot be safely self-administered during transport (may include members who require the continuation of oxygen therapy initiated during the hospitalization from which the transport is being requested when he/she does not have portable oxygen equipment) (i.e., Z74.3).

NON-EMERGENT TRANSPORTATION CRITERIA:

Non-Emergent Ground Transportation

Harvard Pilgrim Health Care (HPHC) considers non-emergent ground transportation as reasonable and medically necessary when BOTH the following are met:

1. The PCP or attending provider determines such transportation is reasonable and medically necessary (based on the patient's medical condition), and the use of less restrictive methods of transportation (e.g., private car, taxi) is contraindicated or likely to endanger the member's health; AND
2. Harvard Pilgrim determines non-emergent ground transportation is reasonable and medically necessary to ensure the member's safe transport ONLY from an origin to a destination listed in table below.

HPHC Medical Policy

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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members' unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g.

Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

Wheelchair Van Transportation

Wheelchair Van Transportation

Wheelchair van transportation may be covered in lieu of ambulance transportation or to and from scheduled medical appointments when Harvard Pilgrim StrideSM (HMO) Medicare Advantage determines general criteria for transport (listed above) are met and service is reasonable and medically necessary to safely transport a wheelchair-dependent member who:

• Is unable to ambulate with or without assistance, and with or without an assistive device; AND
• Is unable to safely transfer from a wheelchair to a private vehicle, with or without assistance; AND
• Requires medical transportation whenever he/she accesses the community for any purpose and cannot be safely transported by private car or taxi.

Non-Emergent Fixed-Wing Air Ambulance

Non-Emergent Fixed-Wing Air Ambulance

Harvard Pilgrim Health Care (HPHC) considers non-emergent air ambulance transportation as reasonable and necessary when documentation confirms it is to ensure the member’s safe transfer to the nearest medical facility capable of furnishing medically necessary care, and documentation confirms ALL the following:

• The use of ground or water ambulance transportation is medically contraindicated, or inappropriate to ensure the member’s safe transfer; AND
• The benefits of air ambulance transport outweigh the potential risks; AND
• Clinical documentation confirms ALL the applicable criteria (below) are met:
  1. The member’s medical condition is stable, and the member can be safely transported via air ambulance; AND
  2. The member requires medical attention/supervision during transport and meets ANY of the following:
     • Requires medical assistance (e.g., suctioning, ventilator assistance, regulation of oxygen therapy);
     • Requires isolation due to a communicable disease or hazardous material exposure;
     • Requires a major orthopedic device (e.g., backboard, halo-traction, use of pins and traction) that significantly limits his/her ability to be safely transported by other means;
     • Is bed-confined due to a medical condition (i.e., unable to get out of bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair), and/or requires special assistance with positioning to avoid further injury (e.g. member cannot be safely positioned in a chair or standard vehicle due to recent or unstable fractures, severe pain, contractures, size, etc.);
  3. Member is considered a danger to self or others.

NOTE: Harvard Pilgrim Health Care (HPHC) may authorize commercial airline transport in lieu of air ambulance services in limited situations where air ambulance transport criteria are met, and a Utilization Management physician or designee determines the member could be safely transported on a commercial (public) airline accompanied by appropriate licensed medical personnel. (Authorization for coverage of commercial airline transportation is limited to charges for transporting the member and necessary medical personnel only.)

Exclusions:

Harvard Pilgrim Health Care (HPHC) considers non-emergent air or ground transportation as not medically necessary when criteria listed in this policy are not met.

In addition, HPHC does not cover:

• Medical transportation, including ambulance or wheelchair van when it is not medically necessary (e.g., for patient/family convenience or preference);
• Transport when an alternate mode of transportation (e.g., taxicab, bus, personal car) is unavailable, or when the member is unable to drive;
• Transportation fee when the member is not transported (even if medical services are provided);
• Types of vehicle used for transport, or medical personnel present during transport that do not meet local, state, and federal regulatory, certification, and licensing requirements

HPHC Medical Policy

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Medical Transportation
VBO1DEC22
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HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.

• Medically necessary services that can be provided quickly, safely, and more cost efficiently on-site than by nonemergency ambulance transport