Prior Authorization Review Panel MCO Policy Submission A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review. Plan: Aetna Better Health Submission Date: 09/04/2018 Policy Number: PA-001 Policy Name: Air Ambulance Transportation Effective Date: Revision Date: Type of Submission Check all that apply: New Policy Revised Policy Annual Review No Revisions* *All revisions to the policy must be highlighted using track changes throughout the document. Please provide any clarifying information for the policy below: CPB PA-001 Air Ambulance Transportation Clinical content was last revised on 08/07/2017. No additional non-clinical updates were made by PA Medicaid Medical Management since the last PARP submission, as documented below. Revision and Update History since last PARP submission: 08/27/2018 - This CPB has been reviewed and maintained. 08/27/2019 Tentative next scheduled review date by PA Medicaid Medical Management. Name of Authorized Individual (Please type or print): Signature of Authorized Individual: Dr. Bernard Lewin, M.D. www.aetnabetterhealth.com/pennsylvania annual 09/04/2018
Last Review: 8/27/2018 Effective Date: 8/7/2017 Next Review: 8/27/2019 Clinical Guidelines: Air Ambulance Transportation Number PA-001 Please see amendment for Pennsylvania Medicaid at the end of this CPB. Medical Necessity Air ambulance transportation, by helicopter or fixed wing aircraft, is medically necessary when the following criteria are met: A. The member s medical condition requires immediate and rapid ambulance transportation that cannot be provided by ground ambulance; that is, the member s condition is such that the time needed to transport by ground, or the instability of transportation by ground, poses a threat to the member s survival or seriously endangers the member s health; AND B. The point of pickup is inaccessible by ground vehicle, such as in remote or sparsely populated areas,or C. Great distances or other obstacles are involved in getting the member to the nearest facility able to provide the appropriate care, such as limited emergency cases where ground transportation is available, but the time required to transport the member by ground rather than air endangers the member s life or health, for example, when it would take a ground ambulance 30-60 minutes or more to transport a member whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the illness or injury. Applicable Billing Codes HCPCS Codes A0140 - Nonemergency transportation and air travel (private or commercial) intra- or interstate A0424 - Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); A0430 - Ambulance service, conventional air services, transport, one way (fixed wing) Page 1
A0431 - Ambulance service, conventional air services, transport, one way (rotary wing) A0435 - Fixed wing air mileage, per statute mile A0436 - Rotary wing air mileage, per statute mile A0999 - Unlisted ambulance service S9960 - Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) S9961 - Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) Revenue Codes 0545 Ambulance - Air Ambulance 0549 Ambulance - Other Ambulance Related Policies and References 1. Pennsylvania HealthChoices Physical Health Agreement, January 1, 2017. 2. PA Code Part VII. Emergency Medical Services. http://www.nasemso.org/legislation/pennsylvania/pennsylvania.html. Accessed May 18, 2017. 3. EncoderPro.com Professional.Accessedathttps://www.encoderpro.com/epro/. 4. Aetna Better Health Policy 7100.05. Prior Authorization. 5. American College of Emergency Physicians. Appropriate and safe utilization of helicopter emergency medical services. Policy Statement. Annals of Emergency Medicine 2014 May; 63(5):627. 6. American College of Emergency Physicians and National Association of EMS Physicians. Guidelines for air medical dispatch: policy resource and education paper, 2006. 7. Floccare DJ, Stuhlmiller DF, et al. Appropriate and safe utilization of helicopter emergency medical services: a joint position statement with resource document. Prehospital Emergency Care 2013 Oct-Dec;17(4):521-525. 8. Galvagno SM, Thomas S et al. Helicopter emergency medical services for adults with Page 2
major trauma. Cochrane Database of Systematic Reviews 2013. Issue 3. 9. Stewart CL, Metzger RR et al. Helicopter versus ground emergency medical services for the transportation of traumatically injured children. Journal of Pediatric Surgery 2015 Feb;50(2):347-352. 10. Appropriate Utilization of Air Medical Transport in the Out of Hospital Setting. American College of Emergency Physicians (ACEP). March/1999; Revised April/2008. 11. Widmeier K. Understanding When to Request a Helicopter for Your Patient. Journal of Emergency Medical Services (JEMS). October 3, 2014; 39(10). 12. Medicare Benefit Policy Manual, Chapter 10 - Ambulance Services. https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/bp102c10.pdf, accessed May 18, 2017. Page 3
AETNA BETTER HEALTH OF PENNSYLVANIA Amendment to Aetna Clinical Policy Bulletin Number: PA-001 Air Ambulance Transportation There are no amendments for Medicaid. www.aetnabetterhealth.com/pennsylvania Annual 09/04/2018