A physician certification for Medicare coverage for ambulance services is not the final word. An ambulance service also must demonstrate the beneficiary’s condition and establish medical necessity when transporting the Medicare beneficiary. In a recent Southern District of Texas decision, the Court affirmed a decision by the Department of Health and Human Services (“HHS”) to deny payment to an ambulance service that provided repeated non-emergency transport to a Medicare beneficiary when the service failed to show that transportation by another means was contraindicated by the patient’s condition.

In the case reviewed by the Southern District of Texas,[1]the ambulance service provided non-emergency transfers of patients between their homes and health care facilities, specifically to Medicare beneficiaries. The ambulance service provided transportation to an 81-year-old Medicare beneficiary six times from her residence to a hospital for hyperbaric wound care and debridement treatments. The submitted claims were denied and an audit was triggered. The ambulance service appealed the denial, but the decision was affirmed at all administrative levels, including a decision issued by HHS on November 1, 2017.

Ambulance services are paid by Medicare only if a beneficiary’s medical condition does not allow for other forms of transportation. As such, medical necessity is critical in determining whether Medicare will provide coverage. Medical necessity is shown when the condition must requireboththe ambulance transportation itself and the level of service provided. Non-emergency transportation is appropriate if the beneficiary is bed-confined and it is documented that other forms of transportation are contraindicated, given the Medicare beneficiary’s condition, or if ambulance transportation is medically required, regardless of bed confinement. In order for Medicare to cover medically necessary non-emergency, scheduled, repetitive ambulance services, the ambulance provider must obtain proper physician certification certifying the Medicare beneficiary’s medical necessity.

In the case at issue, HHS determined that Medicare does not cover the ambulance services at issue. While the ambulance service obtained a physician certification statement for the repetitive, nonemergency ambulance services, the record failed to show that the Medicare beneficiary’s condition contraindicated other methods of transportation. Ambulance reports did not provide a detailed description of the beneficiary’s condition at the time of transport. Accordingly, the court upheld HHS’s determination as supported by the evidence.