Does Medicare Cover Non-Emergency Ambulance Transport?

Medicare Part B covers non-emergency ambulance transport under specific circumstances. Coverage hinges on meeting medical necessity criteria and, for some services, a prior authorization process. Understanding these conditions, documentation requirements, and financial responsibilities is important for beneficiaries.

Medicare Part B Coverage Conditions

Medicare Part B covers non-emergency ambulance services when a beneficiary’s health condition necessitates transport to receive medically necessary services, and other forms of transportation would endanger their health. These transports typically involve movement to or from a doctor’s office, hospital, or skilled nursing facility. Coverage is not for convenience or when alternative, less costly transportation methods are safely available.

Medical necessity means the patient’s health would be jeopardized if transported by means other than an ambulance. For example, Medicare does not cover transport by wheelchair van or a regular car if those options are safe. The transport must also be to the nearest appropriate medical facility capable of providing the necessary level of care.

Demonstrating Medical Necessity

Proving medical necessity for non-emergency ambulance transport requires specific documentation from the treating physician. The physician’s certification must explain why other forms of transport are unsafe for the patient’s medical condition.

A Physician Certification Statement (PCS) must detail the patient’s condition preventing alternative transport and specify the destination. For repetitive, scheduled non-emergent services, the PCS must be signed and dated by the attending physician no earlier than 60 days before the service. This statement alone does not guarantee coverage; it must align with the patient’s medical records.

Medicare considers a patient “bed-confined” if they are unable to get up from bed without assistance, unable to walk, and unable to sit in a chair or wheelchair. This condition is a common example that can meet medical necessity criteria. Other situations include requiring continuous medical monitoring or specific medical procedures during transit, such as oxygen administration or intravenous medications.

Prior Authorization for Specific Transports

Prior authorization from Medicare is mandatory for certain non-emergency ambulance transports, even if medical necessity is established. This applies primarily to repetitive, scheduled non-emergent ambulance transports (RSNAT). RSNAT are defined as medically necessary ambulance services furnished in three or more round trips during a 10-day period, or at least one round trip per week for at least three weeks.

Common examples of RSNAT include transports to and from dialysis treatments or certain cancer treatments. The ambulance supplier is responsible for submitting the prior authorization request.

While prior authorization for RSNAT is voluntary, not obtaining it before the fourth round trip in a 30-day period will result in a prepayment medical review, which can lead to denial. A prior authorization decision can affirm up to 40 round trips within a 60-day period, helping ensure payment. The standard review timeframe for a decision is seven calendar days.

Understanding Your Costs and Appeal Rights

When Medicare covers non-emergency ambulance transport, beneficiaries are responsible for out-of-pocket costs. After meeting the annual Medicare Part B deductible ($257 in 2025), beneficiaries typically pay a 20% coinsurance of the Medicare-approved amount. An average ambulance trip can range from several hundred to several thousand dollars, making the 20% coinsurance potentially significant.

Medicare Advantage plans must cover all services Original Medicare covers, including medically necessary ambulance services. These plans may have different cost-sharing rules, such as varying copayments or deductibles, so beneficiaries should consult their specific plan for details. Medigap policies can help cover the Part B deductible and coinsurance, reducing out-of-pocket expenses.

If a claim for non-emergency ambulance transport is denied, beneficiaries have the right to appeal the decision. Common reasons for denial include insufficient documentation of medical necessity or failure to obtain required prior authorization.

The first level of appeal is a Redetermination, which must be requested within 120 days of receiving the Medicare Summary Notice (MSN) that indicates the denial. If the redetermination is unfavorable, a beneficiary can request a Reconsideration, reviewed by an independent third party. Further appeals can proceed to an Administrative Law Judge (ALJ) hearing, followed by the Medicare Appeals Council, and finally, judicial review in federal district court if specific dollar thresholds are met.