Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 05/01/2014 Title: Ambulance Services
Revision Date: 07/31/2023 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)    No prior authorization will be required for emergency, urgent, or non-urgent ground or air ambulance services. All claims are subject to a medical necessity review.

3)    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.

4)    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 covered.

c)    Use of air ambulance in a non-emergency situation will not be covered if medical necessity is not met.

5)    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.

6)    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.

7)    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

I.     It is the policy of health plans affiliated with Centene Corporation® that air ambulance (fixed wing or rotary wing) transportation is medically necessary when all the following criteria are met:

A.   Transport by either basic or advanced life support ground ambulance would endanger the health or threaten survival of the member/enrollee. Some examples of applicable conditions include, but are not limited to:

1.    Intracranial bleeding requiring neurosurgical intervention;

2.    Cardiogenic shock;

3.    Burns requiring treatment in a burn center;

4.    Conditions requiring treatment in a Hyperbaric Oxygen Unit;

5.    Multiple severe injuries;

6.    Life-threatening trauma;

B.   The location of the member/enrollee needing transport meets any of the following:

1.    The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States);

2.    Great distances or other obstacles, including traffic, or travel time exceeding 30 to 60 minutes, are involved in getting the patient to the nearest hospital with appropriate facilities via ground transportation (examples: burn care, cardiac care, trauma care, critical care, etc.);

C.   If transport is requested from one facility to the other, the transferring facility does not have the appropriate services and physician specialists to provide the necessary medical care (e.g., trauma unit, burn unit, cardiac care unit, or pediatric specialty services).

 

II.    It is the policy of health plans affiliated with Centene Corporation that air ambulance transportation is not medically necessary for any of the following:

A.   Member/enrollee is legally pronounced dead before the ambulance is called;

B.   Transportation is provided primarily for the convenience of the member/enrollee, member’s/enrollee’s family, or the physician;

C.   Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or home;

D.   Transportation to receive a service considered not medically necessary, even if the destination is an appropriate facility.


Limits

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


Background

Air ambulances are used to expeditiously transport critically ill patients during life-threatening emergencies when either great distances or other obstacles such as heavy traffic, preclude such rapid delivery to the nearest appropriate facility.4 Transport by air ambulance may also be necessary when accessibility by a ground ambulance is not possible. Air ambulance transportation is widely regarded as having a beneficial impact on improving the chances of survival and recovery for trauma victims and other critical patients, particularly in rural areas that lack readily accessible advanced-care facilities such as trauma or burn centers. According to the Association of Air Medical Services, it is estimated that in the United Stated over 550,000 patients utilize air ambulance services each year.4

 

Rotary wing transport is ideal for transporting critical trauma patients from the scene as they have the ability to land close to the scene of the incident. They can also be utilized for emergent facility-to-facility transport. However, fuel capacity gives them a relatively short range. The fixed wing aircraft is generally used for emergent facility-to-facility transports when a patient must be transported a long distance.4 They have the ability to travel at much faster speeds then helicopters, with ranges over 500 miles at speeds between 200 to 300 mph.7 Runway requirements for takeoff and landing restrict airplanes, and the patient will usually need one or more transfers involving a ground unit to move them to/from the runway/airport. Fixed wing aircraft provides a transparent hospital-like environment with cardiac monitoring, invasive hemodynamic monitoring, infusion therapy, pulse oximetry, emergency medication, defibrillation with pacing capabilities, and advanced airway management capabilities and is staffed with a flight crew specially trained to provide emergency and critical care medical support.


Reference

Reviews, Revisions, and Approvals

Revision

Date

Approval Date

Policy developed

 

5/2014

Annual Review

 

6/2015

Annual Review

 

6/2016

Adhoc Review: Added claim statement to configure payment of claims with specific diagnosis codes compatible with medical instability.  All other diagnosis codes will be configured to deny for medical records to review medical necessity.

1/1/2017

1/2017

Annual Review: added Air ambulance transport under 10 miles excluded unless extenuating circumstances precluding ground transport.

7/1/2017

7/2017

Annual Review

 

6/2018

Annual Review: Added 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.

4/1/2019

6/2019

Annual Review

 

6/2020

Annual Review

 

6/2021

Annual Review

 

6/2023

Annual Review: Added language to item 2 under public statement on no authorizations required, amended item 4 for medical necessity coverage, replaced medical statement with Centene policy on air ambulance, replaced background information with Centene background information from policy

7/31/023

8/3/2023


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.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.