Medical policy: Non-Emergent Ground Transport Services

Policy number: MP 3.009

Effective date: 10/1/2026

Policy

This policy addresses clinical guidelines that apply to ambulance services and will be used to determine coverage in conjunction with the member’s benefits, the network provider’s agreement with Capital Blue Cross, and any applicable ambulance billing guidelines.

Non-emergent ground medical transportation

Non-emergent ambulance transport (land) may be medically necessary when there is documented evidence that the individual’s medical condition is such that transport by ambulance is required for at least one of the following reasons:

• Need for continuous supervision
• Physical restraint status
• Dependence on other enabling machines and devices

Non-emergent inter-facility transportation

Medical transportation services between hospitals or other healthcare facilities may be medically necessary when all of the following conditions are met:

• The individual meets criteria for non emergent ground medical transport (above); AND
• Services required to treat an individual’s condition are not available in the original facility; AND
• The individual is transported to the most appropriate facility that can provide the necessary service AND
• The transportation service is not rendered for the convenience of the individual, the individual’s family or provider

Policy guidelines

Individuals are usually bed confined when there is a need for an ambulance. The term "bed confined" is not synonymous with "bed rest", “bedridden” or "non-ambulatory." Instead it is an element of the individual’s current condition. Examples include but are not limited to:

• Restraint (actual or potential) to prevent injury to the individual or others
• Immobility due to a fracture that has not been set or the possibility of a fracture
• Advanced airway management
• Morbid obesity requiring additional personnel or equipment

This policy applies to individuals with mental health conditions that require continuous supervision to maintain their safety and/or the safety of others.

If the individual can be safely transported in a wheelchair van, stretcher van, car or taxi, without clinical intervention, ambulance transport is not medically necessary.

Cross-references

• MP 4.003 Medical Necessity
• MP 3.017 Air and Water Ambulance Services

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/background

Ambulance and medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured individuals. These services may involve ground, water, or air transports in both emergency and non-emergency situations.

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, as well as non-emergency situations. The vehicle must comply with state and local laws governing the licensing and certification of an emergency medical transport vehicle. At a minimum, the vehicle must contain a stretcher, linens, emergency medical supplies, and oxygen equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state and local law.

Rationale

N/A

Definitions

Emergency services - Any healthcare services provided after the onset of a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of sufficient severity or severe pain, such 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 any of the following:

• Placing the health of the individual or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy
• Serious impairment to bodily functions.
• Serious dysfunction of any bodily organ or part.
• Other serious medical consequences.
• Transportation, treatment, and related emergency services provided by a licensed emergency medical services agency if the condition is as described in this definition.

Emergency medical services agency (EMS agency) - An entity that engages in the business or service of providing emergency medical services to individuals by operating any of the following:

• An ambulance
• An advanced life support squad vehicle
• A basic life support squad vehicle
• A quick response service
• A special operations EMS service including, but not limited to the following:
  • A tactical EMS service
  • A wilderness EMS service
  • An urban search and rescue EMS service
• A vehicle or service that provides emergency medical services outside of a healthcare facility

Emergency medical services provider (EMS provider) - A certified or licensed team member of a EMS agency. This includes, but it not limited to:

• An emergency medical responder.
• An emergency medical technician.
• An advanced emergency medical technician.
• A paramedic.
• A prehospital registered nurse.
• A prehospital physician extender.
• A prehospital emergency medical services physician.
• An individual prescribed by regulation of the Pennsylvania Department of Health to provide specialized emergency medical services.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These polices are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Paramedic intercept services

Non-emergent ambulance services

Medical Necessity ICD-10 codes selected from the list below must reflect the functional conditions for which the individual requires the ambulance transport.

Medical necessity ICD-10 codes

• Code Z74.3 may be used to indicate cardiac/hemodynamic monitoring required
• Code Z78.1 may be used to indicate need for continuous monitoring to ensure individual safety related to being a danger to self and/or others
• Code Z99.89 may be used to indicate the need to:
  • Maintain continuous intravenous infusion(s)
  • Have healthcare provider administered intravenous/injectable medications en route
  • Provide ongoing airway management/monitoring
  • Continue dependence on multiple machines/devices

References

1. Bulger E, Guffey D, Guyette F, et al. Impact of prehospital mode of transport after severe injury: A multicenter evaluation from the resuscitation outcomes consortium. JTrauma Acutecare Surg. 2012 March;72(3):567-803.
2. Centers for Medicare and Medicaid Services (CMS) Medicare Benefit Policy Manual. Publication 100-02. Chapter 10, Ambulance Services, and Chapter 15, Covered Medical and Other Health Services. Revised 04-13-18.
3. Pennsylvania Insurance Company Law of 1921.
4. Pennsylvania Department of Health Title 35.
5. Pennsylvania Legislative Reference Bureau, Pennsylvania Laws Relating to Emergency Services.
6. American College of Emergency Physicians. Policy Statements.