Medical Policy

Effective Date:05/01/2014 Title:Ambulance Services
Revision Date:04/01/2019 Document:BI445:00
CPT Code(s):A0430-A0431
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    QualChoice covers Medically Necessary licensed ambulance transportation services according to the terms listed in your Benefit Summary and your EOC/COC.

2)    Ground transportation is generally the preferred method.  All air ambulance services are reviewed for Medical Necessity, and coverage will not be provided if it is determined that ground transportation was appropriate.

3)    Transfer from one facility to another.

a)    Ambulance transportation from one facility to another for the reasons specified in your EOC/COC is covered when coordinated prior to the transfer through the QualChoice Care Management department. 

b)    Use of air ambulance for inter-facility transfer in an emergency situation is subject to review for Medical Necessity

c)    Use of air ambulance in a non-emergency situation will NOT be covered unless coordinated by QualChoice Care Management prior to transfer.

4)    Air ambulance transportation may be necessary for patients with major trauma, if reduction in transport time is likely to make a difference in outcome AND if transportation by air (including the increase in time to dispatch, load, and unload) will significantly reduce total transport time. Air ambulance transport for distances less than10 miles will not be covered unless there are well documented extenuating circumstances that preclude ground transportation.

5)    Air transportation benefits must be weighed against the risks of air travel, including risk of crash, risk to medical personnel, risks related to air pressure changes, and increased difficulty of performing certain medical maneuvers in flight.

6)    Air transportation will not be covered when the time of transportation is unlikely to influence the patient’s outcome, such as patients with trauma that is not life- or limb-threatening, patients with stroke who will not arrive at a stroke center in less than three hours from the start of symptoms, or patients with symptoms of stroke that are improving.

Medical Statement

1)    QualChoice considers air transportation Medically Necessary for unstable patients with major trauma who are transported from the site of trauma to a level 1 or 2 trauma center, when such transportation can be accomplished more rapidly by air than by ground (taking into account the entire time involved). 

Examples of major trauma include:

·         Head injury with new neurological deficits

·         Major hemorrhage

·         Evidence of intra-abdominal bleeding

·         Open chest wounds

·         Extremity trauma with loss of distal pulses

·         Trauma with hemodynamic, respiratory, or neurological instability

2)    QualChoice considers air transportation Medically Necessary for inter-facility transfer to a higher level of care in certain emergency situations when such transportation can be accomplished more rapidly by air than by ground (taking into account the entire time involved). 

Examples of such emergency transfer may include:

·         A patient with a head injury and progressing neurological deficit, in a facility without neurosurgical services available

·         A patient with limb-threatening trauma, in a facility without orthopedic services available

·         A patient with chest trauma and progressing respiratory distress, in a facility without thoracic surgery services available

·         A patient requiring emergency coronary revascularization, in a facility without interventional cardiology and/or cardiovascular surgical services available

3)    QualChoice considers air transportation to not be Medically Necessary for patients in whom time of transport is unlikely to influence the patient’s outcome.  Examples include (not an all in-inclusive list):

·         Patients with trauma that is not life- or limb-threatening, and who have stable vital signs

·         Patients with new symptoms of stroke, in whom transportation would not result in arrival at a stroke center less than three hours after onset of symptoms

·         Patients with neurological symptoms that are resolving

4)    QualChoice considers air transportation to not be Medically Necessary when transportation by air cannot be accomplished more rapidly than by ground, taking into account the entire time involved. Air ambulance transport for distances less than10 miles will not be covered unless there are well documented extenuating circumstances that preclude ground transportation.

5)    Air ambulance transport due to diversion status of a facility with appropriate level of care, requires submission of contemporaneous documentation verifying diversion status at the time of transport.


Limits on the annual number of trips or the cost per trip are defined in the Benefit Summary.


1)      Walcott BP, Coumans J-V, Mian MK, Nahed BV, Kahle KT (2011) Inter-facility Helicopter Ambulance Transport of Neurosurgical Patients: Observations, Utilization, and Outcomes from a Quaternary Level Care Hospital. PLoS ONE 6(10): e26216. doi:10.1371/journal.pone.0026216

2)      Arfken CL, et al.  Effectiveness of helicopter versus ground ambulance services for inter-facility transport.  J Trauma.  1998 Oct;45(4):785-90

3)      Brown JB, et al.  Helicopters improve survival in seriously injured patients requiring inter-facility transfer for definitive care.  J Trauma. 2011 Feb; 70(2):310-4.

4)      Taylor, CM, et al. A systematic review of the costs and benefits of helicopter emergency medical services.  Injury. 2010 Jan; 41(1):10-20.Svenson JE, O’Connor JE, Lindsay MB.  Is air transport faster:  A comparison of air versus ground transport times for inter-facility transfers in a regional referral system.  Air Med J. 2006 Jul-Aug;25(4):170-2M.

5)      Kit Delgado, Kristan L. Staudenmayer, N. Ewen Wang, David A. Spain, Sharada Weir, Douglas K. Owens, Jeremy D. Goldhaber-Fiebert. Cost-Effectiveness of Helicopter versus Ground Emergency Medical Services for Trauma Scene Transport in the United States. Annals of Emergency Medicine, 2013

6)      Joshua B. Brown, Nicole A. Stassen, Paul E. Bankey, Ayodele T. Sangosanya, Julius D. Cheng, Mark L. Gestring. Helicopters and the Civilian Trauma System: National Utilization Patterns Demonstrate Improved Outcomes After Traumatic Injury. The Journal of Trauma: Injury, Infection, and Critical Care, 2010; 69 (5): 1030

7)      Nicholl JP, Brazier JE, Snooks HA.  Effects of London helicopter emergency medical service on survival after trauma.  BMJ. Jul22, 1995; 311(6999): 217-222

8)      Snooks HA, et al.  The costs and benefits of helicopter emergency ambulance services in England and Wales.  J Public Health Med. 1996 Mar:18(1):67-77

9)      Taylor C, et al.  The cost-effectiveness of physician staffed Helicopter Emergency Medical Service (HEMS) transport to a major trauma centre in NSW, Australia. Injury. 2012 Nov; 43(11):1843-9.

10)   Black JJM, Ward ME, Lockey DJ.  Appropriate use of helicopters to transport trauma patients from incident scene to hospital in the United Kingdom:  an algorithm.  Emerg Med J 2004;21:355-361

11)   Brown BS et al. Helicopter EMS Transport Outcomes Literature:  annotated review of articles published 2007-2011.  Emer Med Int’l 2012; 2012:876703

12)   Oklahoma Trauma Triage, Transport and Transfer Algorithm accessed 03/17/2014

13)   Arkansas Trauma System Rules and Regulations effective December 5, 2002, revised effective March 1, 2009.  accessed 03/17/2014

Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.

Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.