Ambulance service is covered and considered medically necessary when the patient’s condition is such that the use of any other method of transportation is contraindicated.  The following conditions are presumed to meet this requirement:

1.          Patient was transferred in an emergency situation, such as a result of an injury or acute illness.

2.          Needed to be restrained.

3.          Was unconscious or in shock.

4.          Required oxygen or other emergency treatment enroute to a treatment facility.

5.          Immobilization was required because of a fracture or possible fracture.

6.        Patient was suspected of having an acute stroke or myocardial infraction.

7.          Was experiencing severe hemorrhage.

8.          Was bed confined before and after the ambulance trip.

9.          Could be moved only by stretcher.


Note:  In the absence of any of the above, additional documentation should be obtained to establish whether coverage is appropriate based on benefit policy.


As a general rule, only local transportation by ambulance is covered.  This means the patient must have been transported to the nearest institution with appropriate facilities for treatment of the injury or illness.  Once medical necessity for the ambulance transfer has been established, unless the ambulance charge appears excessive or some other reason exists to question the location of the admitting hospital, it can be assumed the nearest hospital was used.