Medicare beneficiaries sometimes receive an unpleasant surprise in
the mail soon after receiving doctor-ordered or emergency ambulance
services: a bill from the ambulance company for the full amount of
the services received. This Alert is the first in a series about
Medicare's coverage of ambulance services. Here, we discuss common
problems involving Medicare's "origin and destination" and "medical
necessity" requirements. In two further installments, we will
address non-medical transports, Notice of Noncoverage problems, and
Paramedic Intercept issues.
Origin and Destination Requirements
Medicare covers ambulance transfers from any point of origin to the
nearest hospital or skilled nursing facility:
"that is capable of furnishing the required level and type of care
for the beneficiary's illness or injury. [The hospital or skilled
nursing facility] must have available the type of physician or
physician specialist needed to treat the beneficiary's condition."
In other words, Medicare will only cover trips from any point of
origin to the "nearest appropriate facility."
It will not pay for a transfer to a medical facility based simply on
beneficiary preference. This standard applies to air ambulance
transfers as well.
Medicare will also cover trips from a hospital to a beneficiary's
home or nursing facility, or from a nursing facility to the nearest
supplier of medically necessary services not available at the
skilled nursing facility (including the return trip), plus trips for
dialysis for ESRD patients, provided, always, that the
medical necessity requirements are also met.
Problems associated with the origin and destination requirements
most often arise when a Medicare beneficiary experiences a medical
crisis outside of his or her hometown or state, and wishes to be
transported to a local hospital or nursing facility for immediate
care or rehabilitation. For example, a beneficiary may experience a
heart attack outside of her home state, and be admitted to a
hospital in that state. If the beneficiary then needs bypass
surgery, for instance, and wishes to have the surgery close to home,
Medicare will not pay for the ambulance transport, via ground or
air, to a hospital in her home state, unless a particular
physician or hospital is the closest one able to address her medical
needs. Likewise, if a beneficiary is dissatisfied with aspects of
service at a skilled nursing facility and wishes to change
facilities, Medicare will generally not pay for her transfer.
Medical Necessity Requirements
Medicare pays for ambulance transport when a beneficiary's medical
condition is such that other means of transportation are
According to its policy, the Centers for Medicare & Medicaid
Services ("CMS") will presume that this requirement is met if the
beneficiary was transported in an emergency situation or was
unconscious, exhibited signs and symptoms of respiratory or cardiac
distress, stroke or severe bleeding, or needed to be constrained or
remain immobile because of a fracture or possibility of fracture.
For non-emergency situations, federal regulations state:
"transportation by ambulance is appropriate if either: the
beneficiary is bed-confined and it is documented that the
beneficiary's condition is such that other methods of transportation
are contraindicated; or, if his or her medical condition,
regardless of bed confinement, is such that transportation by
ambulance is medically required. Thus, bed confinement is not
the sole criterion in determining the medical necessity of ambulance
transportation. It is one factor that is considered in medical
necessity determinations." 42 C.F.R. §410.40(d) (emphasis
Despite the clear language of this regulation, many ambulance
companies and Medicare contractors interpret it to require
that the beneficiary be wholly bed-confined. Even the CMS policy
manual emphasizes that bed-confinement "is simply one element of the
beneficiary's condition that may be taken into account in the . . .
determination of whether means of transport other than an ambulance
When ambulance companies or Medicare contractors misinterpret this
regulation, beneficiaries receive improper denials.
For example, Mrs. Green was admitted to a hospital from her home
with complaints of chest pain and respiratory distress. She spent a
few days at the hospital undergoing tests. On the day of her
discharge, her doctor wrote an order for her to be taken by
ambulance, based on her weak condition and risk for another cardiac
episode, to a skilled nursing facility for short term
rehabilitation. When the ambulance personnel came to pick her up,
Mrs. Green took a few steps, with the assistance of a nurse, to the
stretcher and was secured. Her transport to the nursing home was
uneventful, and once there, she was helped off the stretcher by a
nurse and took a few steps to her bed at the facility.
Later, at the ambulance company offices, billing personnel read that
the technicians documented that Mrs. Green was able to walk both to
and from the stretcher. The billing agent then submitted the bill
to Medicare as a noncovered claim, based on the fact that
Mrs. Green was not bed bound. Mrs. Green will thus be billed the
full amount of the ambulance service, despite the fact that her
doctor ordered the service and the transport was medically
necessary. This is an improper denial of Medicare coverage for
the ambulance service, and should be appealed. Again, it is the
beneficiary's overall medical condition which must be the focus of
the inquiry, not the beneficiary's bed bound status.
Ambulance services for Medicare beneficiaries are an important
component of Medicare coverage. Medicare covers transport in both
emergency and non-emergency situations to facilities that are
capable of treating the beneficiary's illness or injury, when a
beneficiary's medical condition is such that other means of
transportation are contraindicated.
If a beneficiary receives a bill from an ambulance company,
determine whether the trip met both Medicare's origin and
destination requirements, and medical necessity standard. If so,
challenge the billing via the Medicare appeals process if
Coming Soon: Non-Medical Transports and the Notice of
See Klementowski v. Sec., Dept. of Health and Human
Svcs., 801 F. Supp. 1022, 1028 (W.D.N.Y. 1992).
42 C.F.R. §410.40(e); see also Medicare Benefit
Policy Manual, Chapter 10, §20 – Coverage Guidelines for
Ambulance Service Claims (#3).
Social Security Act §1861(s)(7), 42 U.S.C.
§1395x(s)(7); 42 C.F.R. §410.40(d).
Medicare Benefit Policy Manual, Chapter 10, §20 –
Coverage Guidelines for Ambulance Service Claims (#1 & 2).
Medicare Benefit Policy Manual, Chapter 10, § 10.2.3
– Medicare Policy Concerning Bed-Confinement.