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Policy on Determination of Medical Necessity <br /> INTRODUCTION <br /> A. The accurate determination and documentation of "medical necessity" is extremely important because <br /> payors generally do not reimburse NSMT for transports that are not "medically necessary". For this reason, <br /> payors require documentation to verify that a transport was "medically necessary" before reimbursing for <br /> that transport. Inaccurate determinations of"medical necessity" in claims made to government payors can <br /> subject NSMT to legal liability. <br /> B. "Medical necessity" under Medicare is established when the patient's condition is such that they meet the <br /> criteria for bed confinement or use of any other method of transportation is contraindicated. In other <br /> words, the patient could not be transported by any other means of transportation without endangering <br /> his/her health. If other modes of transportation (such as automobile, taxi, wheelchair-van, bus, etc.) could <br /> have been used without endangering the patient's health, then benefits cannot be paid for ambulance <br /> service. <br /> II. THE DOCUMENTATION OF MEDICAL NECESSITY <br /> A. The documentation of medical necessity is a function of several NSMT components: <br /> 1. intake documentation see NSMT Dispatch Personnel Policy <br /> 2. field provider documentation see Medical Transport Personnel Policy <br /> the billing department's additional research and interpretation of the provided documentation. <br /> B. No government payor shall be billed unless "medical necessity" has been established and documented. <br /> Examples of transports which may be medically necessary include, but are not limited to, the following: <br /> 1. patient requires transport as a result of an emergency <br /> 2. patient needed to be restrained; or <br /> 3. patient was unconscious or in shock; or <br /> 4. patient required emergency oxygen or other emergency treatment on the way to his or her destination; or <br /> 5. patient required oxygen on the way to his/her destination and could not self administer• or regulate his/her <br /> own oxygen; or <br /> 6. patient had to remain immobile because of a fracture that had not been set or the possibility of a fracture; <br /> or F <br /> 7. patient sustained an acute stroke or myocardial infarction; or <br /> 8. patient was experiencing a severe hemorrhage. <br /> 47 <br /> If= <br />