Update: Medicare Coverage for Ambulance Services

On Friday, October 23, 2015, the Centers for Medicare & Medicaid Services (CMS) announced an expansion of the 3-year Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport in accordance with section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015. The model is being expanded to the states of Maryland, Delaware, North Carolina, West Virginia, and Virginia, and the District of Columbia. The expansion begins on January 1, 2016.

Medicare may cover ambulance services, including air ambulance services, if the ambulance service is furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Non-emergent transportation by ambulance is Medicare-coverable if either: (1) the beneficiary is bed-confined and it is documented that the beneficiary’s condition is such that other methods of transportation are contraindicated; or (2) the beneficiary’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Thus, bed confinement is not the sole criterion in determining the medical necessity of non-emergent ambulance transportation; rather, it is one factor that is considered in medical necessity determinations.

A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in three or more round trips during a 10-day period, or at least one round trip per week for at least three weeks.[1] Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment. Medicare may cover repetitive, scheduled, non-emergent transportation by ambulance if: (1) the medical necessity requirements are met; and (2) the ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements are met.[2]

For further information on the prior authorization model for non-emergent ambulance transport, see http://www.gpo.gov/fdsys/pkg/FR-2015-10-23/pdf/2015-27030.pdf or contact Angela Gaston at CMS: (410) 786–7409, or AmbulancePA@cms.hhs.gov.

[1] 42 CFR 410.40(d)(1)
[2] See 42 CFR 410.40(d)(1) and (2). See also 42 CFR 410.40, 410.41, and in the Medicare Benefit Policy Manual (Pub. 100–02), Chapter 10, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.