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16 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> a. contractures creating non-ambulatory status and the beneficiary <br /> cannot sit; <br /> b. immobility of lower extremities(spica cast, fixed hip joints)and <br /> unable to be moved by wheelchair; or <br /> c. return(back)transport, such as when a newborn is transported to a <br /> tertiary hospital for necessary care and services and,when <br /> stabilized, is transported back to the referring hospital to receive a <br /> lower level of services. <br /> 3.2.2.3 Ambulance Services during Pregnancy <br /> Ambulance services for pregnant beneficiaries must be medically <br /> necessary. Medical necessity may be present if one of the following <br /> conditions occur: <br /> a. Crowning; <br /> b. Hemorrhage; <br /> c. Preterm labor(prior to 37 weeks); <br /> d. Premature rupture of membranes; <br /> e. Abruptio placenta; <br /> f. Placenta Previa; <br /> g. Pre-eclampsia or Eclampsia; or <br /> h. Transport from a small hospital to tertiary hospital when <br /> beneficiary is in preterm labor. <br /> 3.2.3 NCHC Additional Criteria Covered <br /> 3.2.3.1 Origin and Destination <br /> NCHC shall cover only emergency ambulance transports that meet all <br /> other program requirements for coverage and only to the following <br /> destinations: <br /> a. Transportation to and from a hospital for inpatient care or <br /> outpatient emergency care; <br /> b. Transportation from a hospital to the nearest facility which is <br /> prepared to accept the beneficiary AND is able to provide needed <br /> service(s)which is(are)not available at the hospital where the <br /> beneficiary is presently confined; <br /> c. Critical access hospital; <br /> d. Transfer site(airport/helipad); <br /> e. Emergency transportation to a physician's office shall meet the <br /> following conditions: <br /> 1. the beneficiary is en route to a hospital; <br /> 2. there is medical need for a professional to stabilize the <br /> beneficiary's condition; and <br /> 3. the ambulance continues the trip to the hospital immediately <br /> after stabilization. <br /> f. Emergency transport from hospital to hospital is appropriate when <br /> the transferring facility does not have adequate facilities to provide <br /> needed care. Coverage is available only if the beneficiary is <br /> transferred to the nearest appropriate facility such as; <br /> transportation between burn centers,trauma units,primary cardiac <br /> intervention centers, and stroke centers. <br /> 20A13 10 <br />