Air ambulance transport includes the provision of services and supplies to a patient transported by fixed wing or rotary wing (helicopter) aircraft

I.    Air Ambulance From an Acute Care Facility

Air ambulance transportation services performed by either a rotary wing aircraft (RW) (e.g., helicopter) or fixed wing aircraft (FW), from an acute care facility (a short term acute care hospital, long term acute care hospital, or acute inpatient rehabilitation hospital) may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

• Aircraft is specially designed and equipped for transporting the sick or injured including customary patient care equipment and supplies, safety and lifesaving equipment; AND
• The ambulance crew consists of at least two attendants. One of these attendants must be duly qualified to provide the medical care required during transport; AND
• The patient's condition is such that the time needed to transport by ground, or the instability of transportation by ground, poses a threat to the patient's survival or seriously endangers the member's health. These include but are not limited to:
  • Intracranial bleeding which requires neurosurgical intervention;
  • Cardiogenic shock;
  • Burns requiring treatment in a burn center;
  • Conditions requiring treatment in a hyperbaric oxygen unit;
  • Multiple severe injuries;
  • Life-threatening trauma;
  • Transplant availability;
• AND
• The sending acute care facility does not have adequate capabilities to provide the required level and type of care to treat the patient’s condition.

Use of an air ambulance to transport a patient from an acute care facility that is capable of treating the patient to another acute care facility is NOT MEDICALLY NECESSARY.

II.   Air Ambulance Transport From a Location Other Than an Acute Care Facility

Air ambulance transportation services performed by either a rotary wing aircraft (RW) (e.g., helicopter) or fixed wing aircraft (FW), from a location other than an acute care facility may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

• Aircraft is specially designed and equipped for transporting the sick or injured including customary patient care equipment and supplies, safety and lifesaving equipment; AND
• The ambulance crew consists of at least two attendants. One of these attendants must be duly qualified to provide the medical care required during transport; AND
• The patient's medical condition requires immediate and rapid ambulance transportation; AND
• The patient cannot be transported by ground ambulance due to either of the following:
  • The point of pick-up is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States); or
  • The patient's condition is such that the time needed to transport by ground ambulance to the nearest hospital with adequate facilities to provide the medical services needed by the patient is greater than 30 minutes.

Documentation Submission:

Documentation supporting the medical necessity criteria described in the policy must be included in the prior authorization, when prior authorization is required. In addition, the following documentation must also be submitted:

• The attending physician order to transfer, including:
  • Reason for the transfer, AND
  • Rationale for selection of the facility chosen.

Link to Pre-Authorization Form:  https://www.bluecrossmn.com/sites/default/files/DAM/2021-12/BCBSMN-Pre-Auth-Request-fillable-X18509R07.pdf