Rotary to ground educational message

When determining transportation to an alternative hospital and to help avoid medical necessity denials for rotary wing air ambulance transports to another hospital, please remember the criteria below.

The use of air and water ambulance services is considered medically necessary when all the following criteria are met:

1. The ambulance must have the necessary equipment and supplies to address the needs of the individual; and
2. The individual’s condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and
3. The individual’s condition is such that the time needed to transport by land poses a threat to the individual’s survival or seriously endangers the individual’s health*; or the individual’s location is such that accessibility is only feasible by air or water transportation; and
4. There is a medical condition that is life threatening, or first responders deem to be life threatening, including, but not limited to, the following:

1. Intracranial bleeding; or
2. Cardiogenic shock; or
3. Major burns requiring immediate treatment in a burn center; or
4. Conditions requiring immediate treatment in a hyperbaric oxygen unit; or
5. Multiple severe injuries; or
6. Transplants; or
7. Limb-threatening trauma; or
8. High risk pregnancy; or
9. Acute myocardial infarction; if this would enable the individual to receive a more timely medically necessary intervention (such as percutaneous transluminal coronary angioplasty [PTCA] or fibrinolytic therapy).

* Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be at least 30 minutes longer than air transport.

For additional details on Clinical UM Guideline CG-ANC-04 Ambulance Services: Air and Ground, please visit the Anthem provider site.

Clinical UM guidelines are subject to change. Administrative services only (ASO) accounts may utilize alternate criteria. All terms and conditions of the member’s benefit plan apply.

For more information, please contact Provider Services:

• Medicaid and Medicare Advantage — 00-450-8753
• Commercial — Please refer to the number on the back of your patient’s member ID card for Provider Services.