Medicare Carriers Manual (CMS PUB 14-3)
Section 2120.2
Necessity and Reasonableness.--To be covered, ambulance service must be medically necessary and reasonable.
A. Necessity for the Service.--Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance service.
B. Reasonableness of the Ambulance Trip.--A claim may be denied on the ground that the use of ambulance service was unreasonable in the treatment of the illness or injury involved (§2303) notwithstanding the fact that the patient's condition may have contraindicated the use of other means of transportation. The carrier should use discretion when applying this principle. It is expected that generally its application will be limited to those instances where a supplier or provider repeatedly demonstrates a pattern of uneconomical practice and to those individual claims where the excess cost is large.
Page2-76/ Rev. 179, 477
10-83 COVERAGE AND LIMITATIONS 2120.3
2120.3 The Destination.--As a general rule, only local transportation by ambulance is covered. This means that the patient must have been transported to a hospital or a skilled nursing home as defined in § 2125 item 3(a) whose locality (see paragraph E below) encompasses the place where the ambulance transportation of the patient began and which would ordinarily be expected to have the appropriate facilities for the treatment of the injury or illness involved. In exceptional situations where the ambulance transportation originates beyond the locality of the institution to which the beneficiary was transported, full payment may be made for such services only if the evidence clearly establishes that such institution is the nearest one with appropriate facilities (see F below). The institution to which a patient is transported need not be a participating institution but must meet at least the requirements of 1861(e)(1) or 1861(j)(1) of the Act. (See §2100.3 A and B for an explanation of these requirements.) A claim for ambulance service to a participating hospital or skilled nursing facility should not be denied on the grounds that there is a nearer nonparticipating institution having appropriate facilities. (See C below for destination exceptions.)
A. Institution to 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 of the locality of such institution and the institution, in relation to the home, is the nearest one with appropriate facilities.
B. Institution to Institution.--Occasionally, the institution to which the patient is initially taken is found to have inadequate facilities to provide the required care and the patient is then transported to a second institution having appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered provided the institution to which the patient is being transferred is determined to be the nearest one with appropriate facilities. In these cases, transportation from such second institution to the patient's home could be covered if the home is within the locality served by that institution, or by the first institution to which the patient was taken.
C. Round-Trip for Specialized Services.--Round-trip ambulance service is covered for a hospital or participating skilled nursing facility inpatient to the nearest hospital or nonhospital treatment facility, i.e., a clinic, therapy center of physician's office to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) not available at the institution where the beneficiary is an inpatient. (See §4168.)
The round-trip ambulance service benefit is subject to all existing coverage requirements and is limited to those cases where the transportation of the patient is less costly than bringing the service to the patient.
Rev. 1004/Page 2-77
2120.3(Cont.) COVERAGE AND LIMITATIONS 10-83
Carriers will monitor this by performing a periodic postpayment review with appropriate medical staff assistance to determine whether the frequency of such ambulance services for a particular patient, together with the medical condition, indicates there is another preferred medical course of treatment. The carrier should not request transfer of hospital inpatients to another hospital capable of providing the required service but should deny such ambulance service claims in the future. For patients in SNFs and those residing at home, the attending physician should be asked to furnish additional information supporting the need for ambulance service relative to the option of admission to a treatment facility.
D. Partial Payment.--Where ambulance service exceeds the limits defined in A, B and C above, refer to §2125 item #5 for instructions on partial payment.
E Locality.--The term "locality" with respect to ambulance service means the service area surrounding the institution from which individuals normally come or are expected to come for hospital or skilled nursing services.
Example: Mr. A becomes ill at home and requires ambulance service to the hospital. The small community in which he lives has a 35 bed hospital. Two large metropolitan hospitals are located some distance from Mr. A's community but they regularly provide hospital services to the community's residents. The community is within the "locality" of the metropolitan hospital and direct ambulance service to either of these (as well as to the local community hospital) is covered.
F Appropriate Facilities.--The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient's condition. However, 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. Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.
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." However, a legal impediment barring a patient's admission would permit a finding that the institution did not have "appropriate facilities." For example, the nearest tuberculosis hospital may be in another State and that State's law precludes admission of nonresidents.
An institution is also not considered an appropriate facility if there is no bed available.
The carrier, however, will presume that there are beds available at the local institutions unless the claimant furnished evidence that none of these institutions had a bed available at the time the ambulance service was provided.
Page 2-78/ Rev. 1004
