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                                     AIR AMBULANCE SERVICES
Protocol: OTH019
Effective Date: September 12, 2011

Table of Contents                                                                                                                            Page

COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE......................................... 1
BACKGROUND ...................................................................................................................................... 5
APPLICABLE CODES ............................................................................................................................ 5
REFERENCES ......................................................................................................................................... 6
PROTOCOL HISTORY/REVISION INFORMATION .......................................................................... 6


INSTRUCTIONS FOR USE
This protocol provides assistance in interpreting UnitedHealthcare benefit plans. When deciding
coverage, the enrollee specific document must be referenced. The terms of an enrollee's document
(e.g., Certificate of Coverage (COC) or Evidence of Coverage (EOC)) may differ greatly. In the event
of a conflict, the enrollee's specific benefit document supersedes this protocol. All reviewers must first
identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage
prior to use of this Protocol. Other Protocols, Policies and Coverage Determination Guidelines may
apply. UnitedHealthcare reserves the right, in its sole discretion, to modify its Protocols, Policies and
Guidelines as necessary. This protocol is provided for informational purposes. It does not constitute
medical advice.

COMMERCIAL, MEDICARE & MEDICAID COVERAGE RATIONALE

A. Air ambulance transportation services, either by means of helicopter or fixed wing aircraft, are
   medically necessary if all of the following criteria are present:

           Air ambulance transportation is provided by an Aeromedical Transport Unit; and
          1.
           Transportation is to an Appropriate Facility for treatment; and
          2.
           Medical Appropriateness of the situation is established; and
          3.
           The Specific Medical Indication required immediate and rapid ambulance transportation
          4.
           that could not have been provided by basic or advanced life support land ambulance.
Please see below for definitions of terms

B. If transport by ambulance was necessary and appropriate, but ground ambulance service would
   have sufficed, payment for the air ambulance service should be the amount payable for ground
   transport (if less costly).
C. If the air transport was medically necessary and appropriate, but the patient could have been treated
   at a closer hospital than the one to which the patient was transported, the air transport payment
   should be limited to the rate for the distance from the point of pickup to the closer hospital.
D. Payment for rural air ambulance services is appropriate only when the request for transport was
   made by a physician or other qualified medical personnel who reasonably determined or certified


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   that the individual’s condition required air transport due to time or geographical factors. The
   following should be considered to be personnel qualified to order air ambulance services:
           1. Physician,
           2. Registered nurse practitioner (from the transferring hospital),
           3. Physician’s assistant (from the transferring hospital),
           4. Paramedic or EMT (at the scene), and,
           5. Trained first responder (at the scene).

Terms and Coverage Criteria:

   1. Aeromedical Transport Unit:

   An aircraft and the trained personnel designated for medical transportation, in-flight monitoring
   and/or treatment. This does not include security aircraft, private aircraft, media-owned aircraft,
   search and rescue aircraft or military aircraft that are not specifically designated for aeromedical
   transportation.

   2. Appropriate Facility:

   A hospital that is capable of providing the required level and type of care for the patient’s
   condition. The facility must also have available the type of physician or physician specialist
   needed to appropriately treat the patient’s condition. In determining whether a particular hospital
   has appropriate facilities, it should be taken into account whether the necessary physicians and
   other relevant medical personnel are available in the hospital at the time the patient is being
   transported. The fact that a more distant hospital is better equipped does not mean that a closer
   hospital does not have appropriate facilities. Such a finding is warranted, however, if the patient’s
   condition requires a higher level of trauma care or other specialized service available only at the
   more distant hospital. Air ambulance services should not be covered for transport to a facility that
   is not an acute care hospital, such as a nursing facility, physician’s office or a patient’s home.

   3. Medical Appropriateness:

   The following situations may justify medical appropriateness:
          a. The medical condition is such that the length of time needed to transport is a direct
             threat to the patient’s survival or seriously endangers the patient’s health
          b. During transport, the patient requires critical care life support and monitoring not
             available from a ground ambulance service
          c. The patient’s condition requires that time spent in transport be as short as possible
          d. Potential delays using ground transportation are likely to worsen the patient’s condition
          e. The point of pickup is inaccessible by land vehicle (remote areas, weather)
          f. Great distances or other obstacles (i.e., heavy traffic) are involved in getting the patient
             to the nearest hospital with appropriate facilities
          g. Ground travel time to the appropriate hospital greater than 30 minutes
          h. When the patient is ready for transport, the air ambulance should be able to deliver the
             patient to the appropriate hospital in a significantly shorter time than ground
             transportation time.



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             i. Total air ambulance transportation time should be estimated using the following
                formula:
                            1. Air ambulance estimated time of arrival +
                            2. Air Ambulance transport time to hospital +
                            3. 15 minutes loading/unloading time

   4. Specific Medical Indications include:

       a.    Intracranial bleeding or obvious skull fracture - requiring neurosurgical intervention
       b.    Cardiogenic shock, excessive blood loss or need for continuous vasoactive medications
       c.    Extensive burns over 20% of body surface requiring treatment in a burn center
       d.    Emergency treatment in a hyperbaric oxygen unit
       e.    Multiple severe injuries in patients with age < 12or > 55
       f.    Two or more long bone fractures
       g.    Penetrating injuries on the body from mid-thigh and above
       h.    Amputation or near-amputation which requires timely evaluation for possible re-
             implantation
       i.    Severe scalping or de-gloving injuries
       j.    Near-drowning with signs of hypoxia or altered mental status
       k.    Pediatric cold-water drowning (with or without cardiac arrest)
       l.    Spinal cord or spinal column injuries with potential for neurologic injury
       m.    Revised Trauma Score < 12; Glasgow Coma Scale < 10; CRAMS  8
       n.    Facial or neck injuries/burns which may result in an unstable airway requiring invasive
             procedures and assisted ventilation
       o.    Hypothermia
       p.    Respiratory or cardiac arrest within 12 hours or current respiratory failure not responsive to
             treatment
       q.    Significant acidosis (pH < 7.2)
       r.    Immediate need for organ transplantation due to severe injury
       s.    Acute myocardial infarction, dissecting aneurysm, or an acute cerebrovascular accident in
             evolution requiring therapy or diagnostic procedures not available at the referring facility
       t.    Status epilepticus
       u.    Known high-risk pregnancy with a serious injury
       v.    Unstable vital signs (hypotension, tachypnea)
       w.    Ejection from a vehicle
       x.    Fall from a height > 20 feet
       y.    Pedestrian or cyclist struck by motor vehicle at > 20 mph
       z.    Fail chest or pneumothorax
       aa.   Major pelvic fracture (unstable pelvic ring disruption, open pelvic fracture)




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Hospital to Hospital Transport

Air ambulance transport may be appropriate for transfer of a patient from one hospital to another if
all of the following criteria are met:

   1. Medical appropriateness criteria (above) are satisfied; and
   2. Transportation by ground ambulance would significantly endanger the patient’s health; and
   3. The transferring hospital does not have adequate or appropriate facilities for the condition; and
   4. The receiving hospital is the nearest one with adequate or appropriate facilities for the
      condition; and
   5. The transfer has been determined medically necessary by a physician at the medical facility
      requesting the transfer of the patient.

Medicare does not have a National Coverage Determination or a Local Coverage Determination for
Nevada for Air Ambulance Services. Accessed April 2011.

There is a Local Coverage Determination for Ambulance Services. This LCD includes the following
information on air ambulances:

Rotary Wing (RW) Air Ambulance
Definition: RW air ambulance is the transportation by a helicopter that is certified by the FAA as a
rotary wing ambulance, including the provision of medically necessary supplies and services.

Rural Air Ambulance Transport (RAAT)
Rural Air Ambulance Transport shall be considered medically necessary when a physician or other
qualified medical personnel orders or certifies the air transport service. The physician or qualified
medical personnel must determine or certify the beneficiary's condition requires air transport due to
time or geographical factors. The following should be considered to be personnel qualified to order air
ambulance services:
    Physician,
    Registered Nurse practitioner,
    Physician's Assistant,
    Paramedic or EMT (at the scene) and
    Trained first responder (at the scene).

Medicare payment can be made only to the closest facility capable of providing the care needed by the
beneficiary regardless of who orders the transport.

For Medicare and Medicaid Determinations Related to States Outside of Nevada:
Please review Local Coverage Determinations that apply to other states outside of Nevada.
http://www.cms.hhs.gov/mcd/search

Important Note: Please also review local carrier Web sites in addition to the Medicare Coverage
database on the Centers for Medicare and Medicaid Services’ Website.




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BACKGROUND

Air ambulance services are generally associated with serious injury and/or catastrophic injuries. In
these types of cases, an authorization request for air ambulance services must not delay definitive
medical treatment of the patient. This guideline must always be followed for non-emergent air
transport requests and for all hospital to hospital air transports. Rural air ambulance services are
services in which the point of pickup of the individual occurs in a rural area or in a rural census tract of
a metropolitan statistical area (as determined under the most recent modification of the Goldsmith
Modification, originally published in the Federal Register on February 27, 1992 (57 Fed. Reg, 6725).


APPLICABLE CODES

The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy
does not imply that the service described by this code is a covered or non-covered health service. Coverage is
determined by the benefit document. This list of codes may not be all inclusive.

    HCPCS Codes             Description
      A0382                 BLS routine disposable supplies
      A0384                 BLS specialized service disposable supplies; defibrillation (used by ALS
                            ambulances and BLS ambulances in jurisdictions where defibrillation is
                            permitted in BLS ambulances)
         A0392              ALS specialized service disposable supplies; defibrillation (to be used only in
                            jurisdictions where defibrillation cannot be performed in BLS ambulances)
         A0394              ALS specialized service disposable supplies; IV drug therapy
         A0396              ALS specialized service disposable supplies; esophageal intubation
         A0398              ALS routing disposable supplies
         A0420              Ambulance waiting time (ALS or BLS), one half (1/2) hour increments
         A0422              Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining
                            situation
         A0424              Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary
                            winged); (requires medical review)
         A0430              Ambulance service, conventional air services, transport, one way (fixed wing)
         A0431              Ambulance service, conventional air services, transport, one way (rotary
                            wing)
         A0432              Paramedic intercept (PI), rural area, transport furnished by a volunteer
                            ambulance company which is prohibited by state law from billing third party
                            payers.
         A0433              Advanced life support, level 2 (ALS 2)
         A0434              Specialty care transport (SCT)
         A0435              Fixed wing air mileage, per statute mile
         A0436              Rotary wing air mileage per statute mile
         A0888              Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond
                            closest appropriate facility)
         A0999              Unlisted ambulance service


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REFERENCES

Centers for Medicare and Medicaid Services. Palmetto GBA (01302). LCD for Ambulance Services,
L28235. Effective September 02, 2008. Revision effective April 2011. Accessed April 2011.

Air Medical Dispatch: Guidelines for Scene Response, National Association of Emergency Medical
Services Physicians, Journal of Pre-hospital and Disaster Medicine, Vol. 7, No 1, March 1992.

Medical Review of Rural Air Ambulance Services. CMS/ DHHS. CMS Manual System Pub. 100-08
Transmittal 102. February 1, 2005. Accessed April 2011.

NAC 450B.568 Air ambulance: Restriction on transfer of patients. Accessed April 2011.

Position Paper on the Appropriate Use of Emergency Air Medical Services, Association of Air
Medical Services, The Journal of Air Medical Transport, September 1990.

Position Paper: Guidelines for Air Medical Dispatch, National Association of EMS Physicians: D.
Thompson & S. Thomas, 2002-2003 Air Medical Services Committee.


PROTOCOL HISTORY/REVISION INFORMATION

        Date             Action/Description
     07/28/2011
                         Corporate Medical Affairs Committee
     03/19/2010




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