For the complete Medicare regulations regarding ambulance services, please click here.

What is required by Medicare for ambulance services to be covered?

To be covered ambulance services must be medically necessary, reasonable (10.2) and to the closest appropriate facility (10.3.6).

What is "Necessity for Service"?

Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated (10.2.1).

In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services (10.2.1).

It is important to note that the presence (or absence) of a physician's order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary (10.2.1).

What is "Reasonableness of the Ambulance Trip"?

Under the fee schedule payment is made according to the level of medically necessary services actually furnished (10.2.2). That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used (10.2.2).

What is Medicare's policy concerning "bed-confinement"?

Medical necessity is established when the patient's condition is such that the use of any other method of transportation is contraindicated (10.2.3). Carriers may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip (10.2.3).

A beneficiary is bed-confined if he/she is:

• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair (10.2.3)

The term "bed confined" is not synonymous with "bed rest" or "non-ambulatory" (10.2.3). Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits (10.2.3). It is simply one element of the beneficiary's condition that may be taken into account in the carrier's determination of whether means of transport other than an ambulance were contraindicated (10.2.3).

What destinations are covered under Medicare for ambulance transports?

An ambulance transport is covered to the nearest APPROPRIATE facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport (10.3). In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient (10.3)

Medicare covers ambulance transports (that meet all other program requirements for coverage) only to the following destinations:

• Hospital;
• Critical Access hospital (CAH);
• Skilled Nursing Facility (SNF);
• Beneficiary's home;
• Dialysis facility for ESRD patient who requires dialysis; or
• A PHYSICIAN'S OFFICE IS NOT A COVERED DESTINATION (10.3). 

As a general rule, ONLY local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered (10.3).

However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered (10.3).

Because all duly licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, may full payment for mileage be considered (10.3).

And then, ONLY if the evidence clearly establishes that the destination institution was the nearest one with appropriate facilities under the particular circumstances (10.3).

Is ambulance transport covered from the institution to the beneficiary's home?

Ambulance service from an institution to the beneficiary's home is covered when the home is within the locality of such institution or where the beneficiary's home is outside the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities (10.3.1).

Is ambulance transportation covered from one institution to another institution?

Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropriate facilities (10.3.2). In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities (10.3.2).

What is considered the closest appropriate facility?

The term "Closest appropriate facility" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved (10.3.6).

The fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities (10.3.6). 

Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist, or a preferred hospital, does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities (10.3.6).

The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have "appropriate facilities" (10.3.6).

Such finding is warranted, however, if the beneficiary requires a higher level of trauma or other specialized service available only at the more distant hospital (10.3.6).


REFERENCE LINK

Medicare Benefit Policy Manual - Chapter 10 Ambulance Services (Rev 133,  10-22-2010).