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9 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> crystalloid,hypotonic,isotonic, and hypertonic solutions <br /> (Dextrose,Normal Saline, or Ringer's Lactate); or <br /> b. At least one of the ALS2 procedures listed below: <br /> 1. Manual defibrillation or cardioversion; <br /> 2. Cardiac pacing; <br /> 3. Endotracheal intubation insertion; <br /> 4. Central venous line; <br /> 5. Intraosseous line; <br /> 6. Chest decompression; <br /> 7. Surgical airway; <br /> 8. 12 Lead electrocardiogram(ECG)for Segment Elevation <br /> Myocardial Infarction[STEMI]; <br /> 9. Continuous Positive Airway Pressure (CPAP); <br /> 10. Ventilator Operation; or <br /> 11. Femoral Line. <br /> 1.1.3 Non-emergency Medically Necessary Ambulance Transport <br /> Non-emergency ambulance transport is a medically necessary transport for a <br /> Medicaid beneficiary to obtain medical services that cannot be provided when <br /> needed at the beneficiary's location, such as computed tomography(CT) scans, <br /> magnetic resonance imaging(MRI), endoscopies,radiation therapy, and dialysis. <br /> 1.1.4 Air Medical Ambulance <br /> Air medical ambulance applies to both rotary-wing and fixed-wing aircraft. <br /> Rotary-wing air medical ambulance is transport by a helicopter that has been <br /> inspected and issued a permit by the State OEMS as a rotary-wing ambulance, <br /> and the provision of medically necessary supplies and services. Fixed-wing air <br /> medical ambulance is transport by a fixed-wing aircraft that has been inspected <br /> and issued a permit by the State OEMS as a fixed-wing air medical ambulance, <br /> and the provision of medically necessary supplies and services. Vehicle and <br /> equipment requirements are located at 1 O NCAC 13P .0209. <br /> 1.1.5 Loaded Mileage <br /> Loaded mileage is the number of miles for which the beneficiary is transported in <br /> the ambulance vehicle. <br /> For air medical ambulance(fixed wing and rotary wing),the point of origin <br /> includes-the beneficiary's loading point and runway taxiing until the beneficiary <br /> is offloaded from the air medical ambulance. Air mileage is based on loaded <br /> miles flown, as expressed in statute miles,and is reimbursable. <br /> For ground ambulance,loaded mileage is from the point of origin to the nearest <br /> appropriate facility. Mileage to a facility that does not meet this criterion is not <br /> covered. Ground ambulance loaded mileage is reimbursable only for out-of- <br /> county transport. In-county loaded ground mileage is not reimbursable. <br /> Out of county transport is a transport by ambulance in which the final <br /> destination of the beneficiary is outside the limits of the county in which the <br /> transport originated. <br /> 20A13 3 <br />