In the absence of coverage criteria from applicable Medicare statutes, regulations, NCDs, LCDs, CMS manuals, or other Medicare coverage documents, this policy uses internal coverage criteria developed by the Company in consideration of peer-reviewed medical literature, clinical practice guidelines, and/or regulatory status.
MEDICALLY NECESSARY
EMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on an emergency basis to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
- There is a medical condition that is life or limb threatening or the professional provider deems to be life or limb threatening, and the individual's condition is such that a delay in transfer poses a threat to the individual's survival or seriously endangers the individual's health or could result in serious impairment to the individual's bodily functions and/or serious dysfunction of any of the individual's bodily organs or parts;
- The necessary diagnostic and/or therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
- The necessary diagnostic and/or therapeutic services are available at the facility to which the individual is being transferred.
- The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
NONEMERGENCY TRANSFERS
Transfer of a registered inpatient from one acute care facility to another acute care facility for inpatient admission on a nonemergency basis to obtain necessary specialized therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
- The necessary therapeutic services are not available at the facility in which the individual is admitted as a registered inpatient;
- The necessary therapeutic services are available at the facility to which the individual is being transferred.
- The individual has been accepted for admission at the nearest appropriate facility that is capable of addressing the individual’s medical needs.
NOT MEDICALLY NECESSARY
Transfer of a registered inpatient from one acute care facility to another acute care facility for any other reason is considered not medically necessary and, therefore, not covered. Examples of transfers that are considered not medically necessary include, but are not limited to, the following situations:
- The requirements in this policy are not met, regardless of the individual's condition.
- The transfer is for the purpose of obtaining a non-covered service.
- The transfer is primarily for the convenience of the individual or the individual's family or healthcare professional.
- The transfer is to return the individual back to the originating facility when the facility to which the individual was transferred is capable of addressing the individual’s medical needs.
REQUIRED DOCUMENTATION
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. 
