Medical Necessity for Nonemergency, Scheduled, Repetitive Ambulance Services Can be Established by a Physician's Certificate Alone
March 21, 2012
By: Aaron Rabinowitz*
AHLA Regulation, Accreditation, and Payment Practice Group Email Alert (American Health Lawyers Association)
On March 8, the U.S. District Court for the Middle District of Tennessee held in First Call Ambulance Service, Inc. v. Department of Health and Human Services that medical necessity for nonemergency, scheduled, repetitive ambulance services can be established by a physician's certificate alone.
First Call Ambulance was an administrative appeal from the final decision of the U.S. Department of Health and Human Services (HHS) Secretary denying Medicare payments for certain ambulance services. HHS argued that physicians' certifications are insufficient to establish medical necessity for nonemergency, scheduled, repetitive ambulance services. HHS maintained that medical necessity must be proven by the beneficiaries' conditions.
The court rejected HHS' position, concluding that a physician's certification alone is sufficient to prove medical necessity and merit Medicare payment for nonemergency, scheduled, repetitive ambulance services. To support its conclusion, the court cited the "plain and unambiguous language" of 42 C.F.R. Section 410.40(d)(2). Consequently, where the service is scheduled and repetitive and the doctor's note is sufficient, additional review of the record to determine medical necessity is not called for under the regulations.
Copyright 2012 American Health Lawyers Association, Washington, DC
Reprint permission granted.
* Aaron Rabinowitz is a former member of the Ober|Kaler Health Law Group.