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UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. UnitedHealthcare ® Medicare Advantage

Policy Guideline

Transportation Services

Guideline Number: MPG320.08

Approval Date: November 10, 2021 Terms and Conditions Table of Contents Page

Policy Summary 1 Applicable Codes 6 Definitions 8 References 9 Guideline History/Revision Information 11 Purpose 11 Terms and Conditions 12 Policy Summary

See Purpose

Overview

Medicare covers ambulance services only if they are furnished to a beneficiary whose medical condition is such tha other means of transportation is contraindicated. A beneficiary whose condition permits transport in any type of veh than an ambulance would not qualify for services under Medicare. The beneficiary's condition at the time of the tran determining factor in whether medical necessity is met. Guidelines

Emergency Ambulance Services (Ground)

Emergency response means responding immediately at the BLS or ALS1 level of service to a 911 call or the equival without a 911 call system. An immediate response is one in which the ambulance provider or supplier begins as qui possible to take the steps necessary to respond to the call. Medicare will cover emergency ambulance services whe services are medically necessary, meet the destination limits of closest appropriate facilities, and are provided by a service that is licensed by the state.

Medical Reasonableness

Medical reasonableness is established if the beneficiary's condition is an emergency and the beneficiary is unable t hospital by other means. An emergency means services provided after the sudden onset of a medical condition, ma itself by acute signs or symptoms of sufficient severity such that the absence of immediate medical attention could be expected to result in the following: placing the beneficiary's health in serious jeopardy; serious impairment to bo functions; or serious dysfunction of any bodily organ or part. Examples of emergency situations are: (Note: This list is not all inclusive.) Injury resulting from an accident, or illness with acute symptoms. Examples are hemorrhage, shock, chest pain, neurological symptoms or respiratory distress.

The beneficiary requires restraints by a professionally trained ambulance attendant as a means of preventing in the beneficiary or to another person. A description of why restraints are necessary is required. Such descriptions include narrative describing specific violent or psychotic acts, frequency/severity/predictability of seizure activit Related Medicare Advantage Reimbursement Policy

• Medicare Physician Fee Schedule Status Indicator, Professional

Related Medicare Advantage Coverage Summary

• Ambulance Services

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UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. precise description of the risk to safety that unrestrained and unsupervised transport would create. A sole diagn senility, forgetfulness, or Alzheimer's does not qualify. Oxygen is required by the beneficiary during transport. The administration of oxygen itself does not satisfy the r that the beneficiary needed oxygen. Documentation should reflect the need such as hypoxemia, syncope, airwa obstruction, and chest pain. Ambulance transport is not medically necessary if the only reason for the ambulanc to provide oxygen during transport, and the beneficiary has a portable oxygen system available. Immobilization of the beneficiary is necessary because of a suspected fracture, a compound fracture, severe pa for pain medication, or suspicion of neurological injury. A transfer is made of a beneficiary between institutions for necessary services not available at the transferring i and the beneficiary meets any of the criteria 1-4 above. Examples are beneficiaries with cardiac disease requirin catheterization or coronary bypass not available at the transferring institution. Destination

An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therape services (such as a CT scan or cobalt therapy) as well as the return transport. In addition to all other coverage requi this transport situation is covered only to the extent of the payment that would be made for bringing the service to Medicare covers ambulance transports (that meet all other program requirements for coverage) only to the followin destinations:

Hospital

Critical Access Hospital (CAH)

Skilled Nursing facility (SNF)

From a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficia resident and not in a covered Part A stay, including the return trip Beneficiary's home

Dialysis facility for ESRD beneficiary who requires dialysis A physician's office is not a covered destination. However, under special circumstances an ambulance transport ma temporarily stop at a physician's office without affecting the coverage status of the transport. Transfer Site (Airport/Helicopter)

As a general rule, only local transportation by an ambulance is covered, and therefore, only mileage to the nearest facility equipped to treat the beneficiary is covered. Non-Emergency (Scheduled) Ambulance Service (Ground) For non-emergency ambulance transportation, transportation by ambulance is appropriate if the beneficiary is bed- and it is documented that the beneficiary's medical condition is such that other methods of transportation are contr or if his or her medical condition, regardless of bed-confinement, is such that transportation by ambulance is medic required.

Three criteria determine whether a beneficiary has Medicare coverage for non-emergency (scheduled) ambulance s Only when transportation by any other means of transportation is contraindicated by the medical condition of th beneficiary

Only to specific destinations; and

Only when certified as medically necessary by a physician directly responsible for the beneficiary's care Note: All three of the above criteria must be met. Medical Reasonableness

Ambulance transport in non-emergency situations must meet medical necessity guidelines. Medical reasonableness is established for non-emergency ambulance services when the beneficiary's condition that the use of any other method of transportation (such as: taxi, private car, wheelchair van, or other type of v Transportation Services Page 3 of 12

UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. contraindicated. If the condition contraindicating other means of transportation is "bed confined", the beneficiar meet the following criteria of "bed confined." The beneficiary is: o Unable to get up from bed without assistance

o Unable to ambulate; and

o Unable to sit in a chair or wheelchair

Note: All three components must be met in order for the beneficiary to be considered "bed-confined." It does no beneficiary who is restricted to bed rest on a physician's instructions due to a short-term illness. Bed confineme is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply o of the beneficiary's condition that may be taken into account in the intermediary's determination of whether me transport other than an ambulance were contraindicated. Examples of situations in which beneficiaries are bed and cannot be moved by wheelchair, but must be moved by stretcher include: o Contractures creating non-ambulatory status and the beneficiary cannot sit o Severe generalized weakness

o Severe vertigo causing inability to remain upright o Immobility of lower extremities (beneficiary in spica cast, fixed hip joints, or lower extremity paralysis) and u moved by wheelchair

If some means of transportation other than an ambulance (such as: private car, wheelchair van, etc.) could be u without endangering the individual's health, whether or not such other transportation is actually available, no p be made for ambulance service.

If transportation is for the purpose of receiving an excluded service (such as a routine dental examination) then transportation is also excluded even if the beneficiary could only have gone by ambulance. If transportation is for the purpose of receiving a service that could have been safely and effectively provided in origin then the transport is not covered even if the beneficiary could only have gone by ambulance. Examples in transport from a residence to a hospital for a service that can be performed more economically in the beneficiar and (b) A transport of a skilled nursing facility beneficiary to a hospital or to another SNF for a service that can b performed more economically in the first SNF.

Ambulance transportation for services excluded from SNF consolidated billing must meet the criteria as reasonable necessary (i.e. other means contraindicated).

Emergency Air Ambulance Transportation

Emergency response means responding immediately at the BLS or ALS1 level of service to a 911 call or the equival without a 911 call system. An immediate response is one in which the ambulance supplier begins as quickly as poss the steps necessary to respond to the call. Medically appropriate air ambulance transportation either by means of a or fixed wing aircraft is a covered service regardless of the state or region in which it is rendered only if the benefici medical condition required immediate and rapid ambulance transportation that could not have been provided by la ambulance, or either:

The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other re sparsely populated areas of the continental United States), or Great distances or other obstacles (for example, heavy traffic) are involved in getting the patient to the nearest appropriate facilities as described in this policy. Medical Reasonableness for Emergency Air Ambulance Transportation Medical reasonableness is only established when the beneficiary's condition is such that the time needed to transpo beneficiary by land, or the instability of transportation by land, poses a threat to the beneficiary's survival or seriou the beneficiary's health. These conditions may include, but are not limited to: Intracranial bleeding - requiring neurosurgical intervention; Cardiogenic shock;

Burns requiring treatment in a Burn Center;

Conditions requiring treatment in a Hyperbaric Oxygen Unit; Multiple severe injuries; or

Life-threatening trauma.

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UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Destination

When all other program requirements for coverage are met, air ambulance transports are covered only to an acute hospital. Air ambulance transports to these destinations are not covered: Nursing facilities

Physicians’ offices

Beneficiaries’ homes

Appropriate Facilities

The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or nursing care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to p services necessary to support the required medical care that determine whether it has appropriate facilities. The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patie warrant a finding that a closer institution does not have "appropriate facilities." Such a finding is warranted, howeve beneficiary's condition requires a higher level of trauma care or other specialized service available only at a more d hospital. In addition, a legal impediment barring a patient's admission would permit a finding that the institution did

"appropriate facilities." For example, the nearest appropriate specialty hospital may be in another State and that St precludes admission of nonresidents.

An institution is also not considered an appropriate facility if there is no bed available. Note: If the transport is for the purpose of receiving a non-covered service, then the transport is also non-covered, e destination is an appropriate facility.

Ambulance Service to a Physician's Office

Ambulance service to a physician's office is covered only under the following circumstances: The ambulance transport is en route to a Medicare covered destination. During the transport, the ambulance stops at a physician's office, because of the beneficiary's dire need for prof attention, and immediately thereafter, the ambulance continues to a covered destination. In such cases, the beneficiary will be deemed to have been transported directly to a covered destination and payme made for a single transport and the entire mileage of the transport, including any additional mileage traveled becau stop at the physician's office.

Physician Certification & Order

Ambulance transport providers or suppliers must obtain a written order from the attending physician for all noneme scheduled repetitive ambulance services and a written statement from the physician certifying the medical necessi ambulance services. Requirements for non-emergency ambulance transportation include: The order and certification must be dated no earlier than 60 days in advance of the transport, for repetitive ben whose transportation is scheduled in advance.

For residents in facilities who are under the direct care of a physician, written orders from the patient's attendin certifying medical necessity can be obtained within 48 hours after the transport. The physician order may be signed by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specia

(where all applicable state licensure or certification requirements are met). For unscheduled non-emergency transports, a registered nurse (RN) or discharge planner who is employed by th beneficiary's attending physician or the hospital or facility where the patient is being treated may sign a physici certification statement on oral orders from the physician or other qualified practitioner (i.e., PA, NP, CNS). The ph must later countersign the written order.

The ambulance supplier is responsible for obtaining the signed written order and certification with the appropria signatures as expeditiously as possible, and must obtain the signed order before billing for the service. If the ambulance supplier is unable to obtain the written order and certification with appropriate signatures with calendar days following the date of the service, the supplier may bill only if there is documentation of good faith obtain the order and certification.

Transportation Services Page 5 of 12

UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. A physician order is not required prior to emergency transports or unscheduled transports of a beneficiary residi or in a facility, who is not under the direct care of a physician. When the transport involves a ground ambulance and an air ambulance, both services may be reimbursed if both a necessary.

Note: It is important to note that the presence of the signed physician certification statement does not necessarily d that the transport was medically necessary. The ambulance provider or supplier must meet all coverage criteria in o payment to be made.

Documentation Requirements

In all cases, the appropriate documentation must be kept on file and, upon request, presented to the contractor. It i to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily pro disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage order for payment to be made.

IOM Pub 100-01, Medicare General Information, Eligibility, and Entitlement Manual, chapter 4 - Physician Certific Recertification of Services, contains specific information on supplier requirements for ambulance certification. IOM Pub. 100-08, Medicare Program Integrity Manual, chapter 6 - Medicare Contractor Medical Review Guideline Specific Services contains information on medical review instructions of ambulance services. Utilization Guidelines

Multiple patient transports - a single payment allowance for mileage will be prorated by the number of beneficiaries Down coding from air to ground is an §1862 (a)(1)(A) denial. Aspirin alone does not qualify to validate as an indicator that an ALS-2 level has been supplied. Oxygen alone, even rates, does not qualify to validate as an indication that an ALS-2 level has been supplied. Administration of IV fluids fluid challenge does not qualify to validate as an indication that an ALS-2 level has been supplied. Nitroglycerin administered as an assist to the beneficiary's own nitroglycerin does not qualify to validate as an indic level has been supplied. Nitroglycerin administered intravenously from the ambulance stock under a physician's tel order, or standing orders does qualify as an indication (as one of three medications) that an ALS-2 level has been su Multiple arrivals - when multiple units respond to a call for services the entity that provides the transport for the ben should be the only provider billing the service.

Billing for Ground Ambulance Services when the Beneficiary is Pronounced Dece Some ambulance providers are incorrectly billing for transports for deceased beneficiaries. According to Pub. 100-02 10, Section 10.2.6, reimbursement of ambulance services provided to a deceased Medicare beneficiary depends on beneficiary is pronounced deceased by an individual authorized to do so. If the beneficiary is pronounced deceased at the scene by an authorized individual after the ambulance is dispa prior to loading, the claim is billed with a QL modifier and no mileage is billed. If the beneficiary is dead at the scene but has not been pronounced by an authorized individual, services are no unless the ambulance waits at the scene for an authorized individual to arrive and pronounce death. The claim i a QL modifier and no mileage is billed.

Medicare reimbursement for the above situations is based on the appropriate Basic Life Support rate using HCPC A0428 or A0429.

When the beneficiary is dead at the scene but has not been pronounced by an authorized individual and the am transports the body to the hospital for pronouncement of death, services are billed and reimbursed at the appro of service furnished.

If the beneficiary is pronounced deceased by an authorized individual prior to ambulance being dispatched no p made.

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UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Billing Procedures When Patient Refuses Transport

Refusal of transport (Procedure code A0998 definition-"Ambulance response and treatment, no transport") is statuto excluded from Medicare coverage and, therefore, is not payable when billed to Medicare. Note: Noridian jurisdiction requires different billing for this service please see the following for further instruction; N Billing Procedures When Patient Refuses Transport

Limitations

Medicare does not cover the following services:

Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned taxicabs

Transportation via Mobile Intensive Care Unit (MICU) (if billed under Part A) Parking fees

Tolls for bridges, tunnels and highways

The IOM Publication 100-04, Chapter 15, Section 40 states: See https://www.cms.gov/Center/Provider-Type/Ambulan Services-Center.html for a medical conditions list and instructions to assist ambulance providers and suppliers to co the patient's condition to Medicare contractors, as reported by the dispatch center and as observed by the ambulan Use of the medical conditions list does not guarantee payment of the claim or payment for a certain level of service In addition to reporting one of the medical conditions on the claim, one of the transportation indicators may be inclu claim to indicate why it was necessary for the patient to be transported in a particular way or circumstance. The pro supplier will place the transportation indicator in the “narrative” field on the claim. Information on the appropriate u transportation indicators is also available at https://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center Effective January 1, 2006, items and services which include but are not limited to oxygen, drugs, extra attendants, s EKG, and night differential are no longer paid separately for ambulance services. This occurred when CMS fully impl the Ambulance Fee Schedule, and therefore, payment is based solely on the ambulance fee schedule. Applicable Codes

The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered service. Benefit coverage for health services is determined by the member specific benefit plan document and appl that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement guarantee claim payment. Other Policies and Guidelines may apply. HCPCS Code 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 routine 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) A0425 Ground mileage, per statute mile

A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) Transportation Services Page 7 of 12

UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. HCPCS Code Description

A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency) A0428 Ambulance service, basic life support, nonemergency transport, (BLS) A0429 Ambulance service, basic life support, emergency transport (BLS, emergency) 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 whic 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 Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate fac

(Non-Covered)

A0998 Ambulance response and treatment, no transport (Non-Covered) A0999 Unlisted ambulance service

Coding Clarification: For ambulance service claims, institutional-based providers and suppliers must report an origin destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination modifiers used for am services are created by combining two alpha characters. Each alpha character, with the exception of “X”, represent code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin second position alpha code equals destination. Origin and destination codes and their descriptions are listed below. Modifier Description

D Community mental health center, FQHC, RHC, urgent care facility, non-provider-based ASC or freestanding emergency center, location furnishing dialysis services and not affiliated with ESRD E Residential, domiciliary, custodial facility (other than 1819 facility) if the facility is the beneficiary G Hospital based ESRD facility

H Alternative care site for hospital, including CAH, provider-based ASC, or freestanding emergency I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport J Freestanding ESRD facility

N Alternative care site for SNF

P Physician’s office

R Beneficiary’s home

S Scene of accident or acute event

X Intermediate stop at physician’s office on way to hospital (destination code only) Revenue Code Description

540 Ambulance

541 Supplies

542 Medical transport

543 Heart mobile

544 Oxygen

545 Air ambulance

546 Neonatal ambulance services

547 Pharmacy

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UnitedHealthcare Medicare Advantage Policy Guideline Approved 11/10/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Revenue Code Description

548 Telephone transmission EKG

549 Other (ALS)

Definitions

Advanced Life Support, Level 1 (ALS1): Advanced life support, level 1 (ALS1) is the transportation by ground ambula vehicle (as defined in section 10.1, above) and the provision of medically necessary supplies and services (as define 10.2, above) including the provision of an ALS assessment by ALS personnel or at least one ALS intervention. Advanced Life Support, Level 1 (ALS1): Emergency: When medically necessary, the provision of ALS1 services, as sp above, in the context of an emergency response, as defined below. Emergency response is a BLS or ALS1 level of se has been provided in immediate response to a 911 call or the equivalent. An immediate response is one in which th ambulance provider/supplier begins as quickly as possible to take the steps necessary to respond to the call. Advanced Life Support, Level 2 (ALS2): Advanced Life Support, level 2 (ALS2) is the transportation by ground ambul vehicle and the provision of medically necessary supplies and services including (1) at least three separate adminis one of more medications by intravenous (IV) push/bolus or by continuous infusion (excluding crystalloid fluids) or (2 ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 proce listed: Manual defibrillation/cardioversion; Endotracheal intubation; Central venous line; Cardiac pacing; Chest deco Surgical airway; or Intraosseous line.

Basic Life Support: Basic life support (BLS) is transportation by ground ambulance vehicle (as defined in section 10. and the provision of medically necessary supplies and services (as defined in section 10.2, above), including BLS am services as defined by the State. The ambulance vehicle must be staffed by at least two people who meet the requi the state and local laws where the services are being furnished, and at least one of the staff members must be cert minimum as an emergency medical technician-basic (EMT-Basic) by the state or local authority where the services a furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. The vary from State to State or within a State. For example, only in some jurisdictions is an EMT-Basic permitted to oper equipment onboard the vehicle, assist more qualified personnel in performing assessments and interventions, and e peripheral intravenous (IV) line.

Basic Life Support (BLS) Emergency: When medically necessary, the provision of BLS services, as specified above, in context of an emergency response (as defined below). Emergency response is a BLS or ALS1 level of service that ha provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulan provider/supplier begins as quickly as possible to take the steps necessary to respond to the call. Fixed Wing Air Ambulance (FW): Fixed wing air ambulance is furnished when the beneficiary's medical condition is s transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambul necessary because the beneficiary's condition requires rapid transport to a treatment facility, and either great dista obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle. Paramedic Intercept (PI): Paramedic Intercept services are ALS services provided by an entity that does not provide ambulance transport. This type of service is most often provided for an emergency ambulance transport in which a volunteer ambulance that can provide only basic life support (BLS) level of service is dispatched to transport a patie patient needs ALS services such as EKG monitoring, chest decompression, or I.V. therapy, another entity dispatches paramedic to meet the BLS ambulance at the scene or once the ambulance is on the way to the hospital. The ALS p then provide services to the patient.

This tiered approach to life saving is cost effective in many areas because most volunteer ambulances do not charg services and one paramedic service can cover many communities. Prior to March 1, 1999, Medicare payment could for these services, but could not be made directly to the intercept service provider

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