Procedures Medications
Arterial Line Monitoring X Any Medication with IV pump X
Balloon Pump with Perfusionist X Antibiotic IV Infusion X
BiPAP X Albuterol or Atrovent SVN Treatments X X
Central Venous Catheter w/o Medications X X X Blood Products X
Central Venous Catheter w/ Medications X Dextrose X X
Cervical Spinal Precautions X X X Diprivan (Propofol) IV Infusion X
CPAP X X Dopamine IV Infusion (no IV pump) X X
Dialysis Shunt X Fentanyl IV Infusion (no IV pump) X X
EKG Monitoring X X Heparin IV Infusion X
External Pacing X X Insulin IV Infusion X
Foley Catheter X X X IV Crystalloid Fluids (NS, LR, D5W) X X
NG/OG Tube (Clamped) X X X IV Lock without Fluids Running X X X
NG/OG Tube with Suction X X KCL (Potassium Chloride) X
Port-A-Cath without Medications X X X Magnesium IV Infusion (no IV pump) X X
Port-A-Cath with Medications X Morphine IV Infusion (no IV pump) X X
Pulse Oximetry X X X Oxygen (Nasal Cannula, Non-Rebreather) X X X
Swan-Ganz Catheter X Pitocin (Oxytocin) IV Infusion X
Thoracostomy Tube (Chest Tube) X Sodium Bicarb Infusion (no IV pump) X X
T-Piece X X X TPA IV Infusion X
Tracheostomy with Ventilator X Total Parenteral Nutrition (TPN) X
Tracheostomy without Ventilator X X X Versed IV Infusion (no IV pump) X X
Ambulance transportation is indicated when it is deemed medically necessary and other means of transportation are contraindicated or would be potentially harmful to the patient.  To meet this requirement, the patient must be “bed confined” OR suffer from a condition in which transport by any other means other than an ambulance is contraindicated by the patient’s condition.


To meet the requirements of “bed confined” the patient must satisfy the following conditions: (1) unable to get up from bed without assistance; AND (2) unable to ambulate; AND (3) unable to sit in a chair or wheelchair.


To certify that a patient meets the definition of medical necessity please complete a Physician Certification Statement (PCS Form).  A PCS Form can be downloaded from