Clinical UM Guideline


Subject: Ambulance Services: Air and Water
Guideline #:  CG-ANC-04 Publish Date:    02/27/2019
Status: Reviewed Last Review Date:    01/24/2019


This document addresses the use of air or water ambulance services. An ambulance is a specially equipped vehicle designed and supplied with materials and devices to provide life-saving and supportive treatments or interventions. Wheel-chair vans or other such vehicles are not so equipped and are not addressed in this document.

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

Clinical Indications

Medically Necessary: 

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).

Mileage associated with an air or water ambulance service is considered medically necessary up to the distance required for transport to the nearest appropriate facility.

The use of air and water ambulance services to transport an individual from one hospital to another requires that:

  1. The above criteria must be met, and
  2. The first hospital does not have the required services and facilities to treat the individual.

The use of air and water ambulance services for deceased individuals is considered medically necessary when the above criteria 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.

Not Medically Necessary: 

All other uses of air and water ambulance services are considered not medically necessary, including, but not limited to, the following:

  1. Transfers from one hospital to another if above criteria not met; or
  2. Transfers from a hospital capable of treating an individual to another hospital primarily for the convenience of the individual or the individual’s family or physician; or
  3. When land transportation is available and the time required to transport the individual by land does not endanger the individual’s life or health; or
  4. Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician’s office or the individual’s home; or
  5. 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 document 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, conventional air services, transport, one way (fixed wing)


Ambulance service, conventional air services, transport, one way (rotary wing)


Fixed wing air mileage, per statute mile


Rotary wing air mileage, per statute mile


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


Unlisted ambulance service [when specified as ambulance service, water transport]


Ambulance service, conventional air services, nonemergency transport, one way (fixed wing)


Ambulance service, conventional air service, nonemergency transport, one way (rotary wing)



ICD-10 Diagnosis



All diagnoses

Discussion/General Information

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 the 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. An air ambulance may be a specially equipped aircraft such as a helicopter of airplane or boats. Water ambulances are specially equipped boats. 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.

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. Funder KS, Rasmussen LS, Lohse N, et al. The impact of a physician-staffed helicopter on outcome in patients admitted to a stroke unit: a prospective observational study. Scand J Trauma Resusc Emerg Med. 2017; 25(1):18.
  2. 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. Policy Statements. Available at: Accessed on December 20, 2018.
    • Emergency Medical Services Interfaces with Health Care Systems (February 2018)
  2. American College of Surgeons. Equipment for Ambulances. April 2009. Available at: Accessed on December 12, 2018.
  3. Doucet J, Bulger E, Sanddal N, et al. Appropriate use of helicopter emergency medical services for transport of trauma patients: guidelines from the Emergency Medical System Subcommittee, Committee on Trauma, American College of Surgeons. J Trauma Acute Care Surg. 2013; 75(4):734-741.
  4. Floccare DJ, Stuhlmiller Df, Braithwaite SA, et al. Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document. Prehosp Emerg Care. 2013; 17(4):521-525.
  5. Palmetto GBA. Local Coverage Determination for Ambulance Services (L34549). Revised 05/31/2018. Available at: Accessed on December 12, 2018.
  6. 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







Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.



MPTAC review. Clarifications to MN and NMN statements regarding mileage. Updated References section.



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



MPTAC review. Updated formatting in Clinical Indications section.



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



MPTAC review. Addition of “first responders deem to be life threatening” to Medically Necessary Statement. Updated Discussion/General Information and References.



MPTAC review. Updated References.



Updated Coding section with 01/01/2014 HCPCS changes.



MPTAC review. Updated References.



MPTAC review. No changes to Clinical Indications.



MPTAC review. Updated Rationale and Reference sections.



MPTAC initial document development. Moved position statement regarding air and water ambulance from CG-ANC-01 to CG-ANC-04.

Pre-Merger Organizations Last Review Date Document Number Title

Anthem Midwest



Air Ambulance Services

Anthem Virginia



Ambulance and Medical Transport

Anthem Maine



Ambulance Benefit Detail