CG-ANC-06 Ambulance Services: Ground; Non-Emergent

This policy addresses non-emergency ground ambulance transportation services (e.g., HCPCS A0380, A0390, A0425, A0426, A0428, A0432, A0434, A0998). Coverage is provided when all are met: the vehicle is a properly equipped ambulance, the patient’s condition makes any other transport medically contraindicated (e.g., truly bed-confined/unable to ambulate or sit), and transport is for interfacility transfer (hospital, skilled nursing facility, or freestanding dialysis center) to obtain medically necessary diagnostic or therapeutic services (e.g., MRI, CT, ICU/NICU, Cobalt therapy). Not covered when these criteria are not met or for other indications; mileage beyond the nearest appropriate location is also not covered.

"Non-emergency ground ambulance services are consideredmedically necessarywhen the following criteria are met (A, B,andC must be met):"

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