Medicare coverage of Ambulance service - conditions

Requirements for Coverage

For ambulance services to be covered by Medicare, the following requirements must be met:
 Actual transportation of the beneficiary occurs.
 Services must be medically necessary and reasonable for the condition of the patient.
 The condition of the patient would not allow transportation by other means.
 A diagnosis must be on the claim or a detailed description of the patient’s condition at the time of transfer must be submitted with the claim or provided upon request to determine medical necessity.
 Ambulance personnel should document their observations of the patient’s condition.
 Transportation to a hospital from another hospital when a patient’s needs cannot be met at the first hospital and the patient is admitted to the second hospital.
 Transportation is to an extended care facility or to the patient’s home.
 Transportation is to the closest appropriate facilities.
 Transportation is provided by an approved supplier/provider of ambulance services.
 The transportation is not part of a Part A (in patient) service.

Medical Necessity
The following conditions may establish that the patient had to be transported by ambulance:
 Patient is transported in an emergency situation; e.g., as a result of an accident or injury.
 Patient needs to be restrained.
 Patient is unconscious or in shock.
 Patient requires oxygen or other emergency treatment on the way to the destination.
 Patient must remain immobile because of a fracture or the possibility of a fracture that has not been set.
 Patient sustains an acute stroke or myocardial infarction.
 Patient is experiencing severe hemorrhaging.
 Patient has a condition that requires him to be moved only by stretcher.
 Patient has a condition that makes him bed-confined before and after the ambulance trip.