Clinical UM Guideline


Subject: Ambulance Services: Ground; Emergent
Guideline #:  CG-ANC-05 Publish Date:    03/29/2018
Status: Revised Last Review Date:    02/27/2018


This document addresses the use of ground ambulances in emergency situations. An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Wheelchair vans or other such vehicles are not equipped as ambulances and are not addressed in this document.

Note: Please see the following related documents for additional information.

Clinical Indications

Medically Necessary:

The use of emergency ground 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. Either of the following circumstances exists:
    1. Transportation from the scene of a life-threatening accident or emergency to the nearest* hospital or physician’s office with appropriate facilities for treatment of an individual’s illness or injury is required; or
    2. Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain emergent medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individual initially resides.

*Mileage associated with an emergency ground ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility.

Emergency ground ambulance services for deceased individuals are considered medically necessary when the criteria above are met and when either of the following is present:

  1. The individual was pronounced dead while in route or upon arrival at the hospital or final destination; or
  2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up. In these circumstances the response to call is considered medically necessary.

Ambulance providers are required to respond to all emergency calls, but occasionally after assessment, transport is declined by the individual. In such cases ambulance services would be considered medically necessary.

Not Medically Necessary:

The use of emergency ground ambulance services is considered not medically necessary when:

  1. The criteria and circumstances above have not been met; or
  2. The services are primarily for the convenience of the individual or the individual’s family or physician; or
  3. The services are for a transfer of a deceased individual to a funeral home, morgue, or hospital, when the individual was pronounced dead at the scene.

Mileage in excess of the distance from the trip origin to the nearest appropriate facility is considered not medically necessary.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.





Ambulance service, neonatal transport, base, rate, emergency transport, one way



BLS mileage (per mile)



ALS mileage (per mile)



Ground mileage, per statute mile



Ambulance service, advanced life support, emergency transport, Level 1 (ASL1-Emergency)



Ambulance service, basic life support, emergency transport (BLS-Emergency)



Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third party payers



Advanced life support, Level 2 (ASL2)



Specialty care transport (SCT)



Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)


Ambulance response and treatment, no transport



ICD-10 Diagnosis



All diagnoses

Discussion/General Information

An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Ambulance transport services involve the use of specially designed and equipped vehicles to transport ill or injured individuals. Ambulance transport may involve the movement of an individual to the nearest hospital for treatment of an individual’s illness or injury, non-emergency medical transport of an individual to another location to obtain medically necessary specialized diagnostic or treatment services, or non-emergency medical transport to a hospital or to an individual’s home. Although wheelchair vans are specially equipped to accommodate physically challenged individuals, they do not have the proper equipment to qualify as an ambulance. Proper equipment may include ventilation and airway equipment, cardiac equipment (monitoring and defibrillation), immobilization devices, bandages, communication equipment, obstetrical kits, infection control, injury prevention equipment, vascular access equipment, and medications.

An ambulance may be either a ground transportation vehicle, such as a specially equipped truck or van, but may also be a properly equipped aircraft or boat. This document specifically addresses only ground transportation-type ambulances.

In general, an emergency medical condition is defined as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

Examples of medical emergencies may include illness or injury such as severe chest pains that might indicate a heart attack, slurred speech or weakness that might indicate a stroke, fracture, hemorrhaging, poisoning, major burns, loss of consciousness or respiratory accidents, convulsions, shock and other acute conditions.


Peer Reviewed Publications:

  1. Galvagno SM Jr, Haut ER, Zafar SN, et al. Association between helicopter vs ground emergency medical services and survival for adults with major trauma. JAMA. 2012; 307(15):1602-1610.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Emergency Physicians. Guidelines for Ambulance Diversion (1999, reaffirmed 2012). Available at: Accessed on February 15, 2018.
  2. American College of Emergency Physicians/National Association of EMS Physicians. Alternate Ambulance Transportation and Destination (2001; reaffirmed 2008). Available at: Accessed on February 15, 2018.
  3. American College of Surgeons Committee on Trauma/American College of Emergency Physicians/National Association of EMS Physicians/American Academy of Pediatrics/National Association of EMS physicians. Equipment for Ambulances (2009). Available at: Accessed on February 15, 2018.
  4. Cahaba Government Benefit Administrators®. Local Coverage Determination for Transportation Services: Ambulance (L34302). Revised 01/30/2018. Available at: Accessed on February 15, 2018.
  5. Novitas Solutions, Inc. Local Coverage Determination for Ambulance (Ground) Services (L35162). Revised 03/16/2017. Available at: Accessed on February 15, 2018.
  6. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 01/29/2018. Available at: Accessed on February 15, 2018.
  7. Thomson DP, Thomas SH; 2002-2003 Air Medical Services Committee of the National Association of EMS Physicians. Guidelines for air medical dispatch. Prehosp Emerg Care. 2007; (2):265-271.

Emergency Transport

Document History






Medical Policy & Technology Assessment Committee (MPTAC) review. Clarifications to MN and NMN statements regarding mileage. Updated Description and References section.



MPTAC review. Revisions made to NMN statement. Coding section updated. The document header wording updated from “Current Effective Date” to “Publish Date.”



MPTAC review. Updated Description, Discussion/General Information, and References sections. Updated formatting in Clinical Indications section.



MPTAC review. Updated References. Removed ICD-9 codes from Coding section.



MPTAC review. Updated References.



MPTAC review. Initial document development created from CG-ANC-01 Ambulance Services: Ground.