Archived Policies - DME
Hospital Beds and Related Equipment
Hospital beds (as identified below by type) are considered medically necessary when meeting specific clinical appropriateness criteria:
Coverage of an Air Fluidized bed may be considered medically necessary when all of the following criteria are met:
Home use of the air-fluidized bed is considered not medically necessary in the following circumstances:
Coverage for the air-fluidized bed is limited to the equipment itself, and does not include reimbursement for the caregiver or, architectural adjustments such as electrical or structural improvements.
Power Flotation Therapy Bed/Alternating Pressure System
May be considered medically necessary if the patient meets one of the following combinations:
Criteria 1, 2 & 3 or
Criteria 4 or
Criteria 5 & 6
Power Floatation Therapy Bed or Alternating Pressure System Criteria Grid
Multiple stages II pressure ulcers located on the trunk or pelvis.
Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate low air loss mattress and/or system.
The ulcers have worsened or remained the same over the past month.
Large or multiple stage III or IV pressure ulcers on the trunk or pelvis.
Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within past 60 days). NOTE: Coverage following a myocutaneous flap or skin graft is generally limited to 60 days from the date of surgery. Continued use of the support surface is covered until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that other aspects of the care plan are being modified to promote healing or use of the support surface is medically necessary for wound management.
Patient has been on an air fluidized bed or power air flotation bed immediately prior to a recent discharge from a hospital or nursing facility.
Beds in this category may include, but are not limited to, Stryker Frame™, Circulo-Electric™ and Oscillatory bed. These beds are not medically necessary as they are considered institutional equipment and inappropriate for home use.
Beds such as the Craftmatic® Adjustable bed and the Sleep Number® bed by Select Comfort Corporation are considered not medically necessary as they are not hospital beds and are not suited for the appropriate care and treatment of patients.
The replacement of a mattress for a medically necessary hospital bed may be considered medically necessary.
An alternating pressure mattress and/or pump or gel/water flotation pad may be considered medically necessary if one of the following combinations is met:
Criteria 2 or 3 with at least one of criteria 4-7
Alternating Pressure Mattress with Pump , or Gel/Water Flotation Pad Criteria Grid
Completely immobile (patient unable to make changes in body position without assistance).
Limited mobility (patient cannot independently make changes in body position enough to alleviate pressure) with.
Any stage pressure ulcer on the trunk or pelvis.
Impaired nutritional status.
Fecal or urinary incontinence.
Altered sensory perception.
Compromised circulatory status.
Bed Side Rails
Bed side rails may be considered medically necessary if required by the patient’s condition and are not an integral part of, or an accessory to a hospital bed. Some indications include but are not limited to:
Bed cradles may be considered medically necessary to prevent contact with bed coverings. Some indications include but are not limited to:
A trapeze bar may be considered medically necessary when a patient needs this device to sit up because of a respiratory condition, to change body position for other medical conditions, or to get in or out of bed.
Bed Boards and Over the Bed Tables
These items are not a covered benefit as they are considered convenience items.
Safety Net Enclosure
The use of safety netting placed over a hospital bed frame or canopy, to prevent falls, is not a covered benefit for home use. These devices are intended for institutional use only.
Hospital beds allow the patient's position to be changed at the head and foot of the bed. In addition, the distance of the bed from the floor can be adjusted. In contrast, an ordinary bed has a fixed height from the floor and has no head or leg elevation adjustment.
The following are descriptions of various types of hospital beds:
Oscillatory beds were designed to assist with repositioning needs of the critically ill. Using a programmed unit, the bed shifts the position of the patient with minimal stimulation therefore reducing the oxygen demands needed for recuperation.
Beds used in the treatment of spinal cord injuries (Circulo-Electric™ RotoRest™ or Stryker Frame™), are found in facilities such as hospitals.
The Craftmatic® Adjustable bed is a semi-electric bed with head and leg adjustment but no height adjustment. It has a choice of wireless or corded hand wand control that adjusts the head and foot of the bed. An electric mattress cover applies heat to that portion of the body touching the mattress. Dual controls are provided for dual-queen and dual king-size beds. A variety of massage options are available on Craftmatic® Adjustable beds. This type of bed is not a hospital bed.
The Sleep Number® bed has firmness settings between zero and 100 that can be adjusted by a hand held device that electronically adjusts the volume of air. Each side can be independently adjusted. A variety of accessories are available such as pillows, comforters, sheets and mattress pads. This type of bed is not a hospital bed.
Coverage for hospital beds must be reasonable and necessary for the treatment of the individual patient. A physician must provide a certificate of medical necessity for the appropriate equipment needed. Medical necessity information should include the diagnosis, a narrative description of the patient's condition, abilities, and limitations and the length of need of the item prescribed. The medical records may include physician’s office records, hospital records, nursing home records, home health agency records, and/or records from other healthcare professionals.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
National Coverage Determination for Hospital Beds (280.7). Durable Medical Equipment Hospital Beds. Publication number 100-3. This is a longstanding national coverage determination. The effective date of this version has not been posted.
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC plans.
Strauss, M.J., Gong, J., et al. The cost of home air-fluidized therapy for pressure sores. Journal of Family Practice (1991 July) 33(1): 52-59.
Nimit, K. Public Health Service Assessment Guidelines for Home Air-Fluidized Therapy. Technology Assessments (1989) 5:1-11 Medline (1992 October).
Perez, E. David M.D. Updated Guidelines for Treatment and Prevention. Geriatrics (1993) 48:39-44.
Ochs, R.F., Horn, S.D., et al. Comparison of air-fluidized therapy with other support surfaces used to treat pressure ulcers in nursing home residents. Ostomy or Wound Management (2005 February) 51 (2): 38-68.
Yonezawa, Y., Miyamoto, Y., et al. A new intelligent bed care system for hospital and home patients. Biomedical Instrumentation and Technology (2005 July-August) 39(4): 313-9.
Catz, A., Zifroni, A., et al. Economic assessment of pressure sore prevention using a computerized mattress system in patients with spinal cord injury. Disability and Rehabilitation (2005 November 15) 27(21):1315-9.
DMERC Manual Pressure Reducing Support Surfaces Group 1 Chapter 32. (2005).
DMERC Manual Pressure Reducing Support Surface Group 2 Chapter 33. (2005)
DMERC Manual Pressure Reducing Support Surfaces Group 3 Chapter 33. (2005)
|Title:||Effective Date:||End Date:|
|Hospital Beds and Related Equipment||01-15-2019||10-14-2019|
|Hospital Beds and Related Equipment||04-01-2017||01-14-2019|
|Hospital Beds and Related Equipment||04-01-2016||03-31-2017|
|Hospital Beds and Related Equipment||07-01-2015||03-31-2016|
|Hospital Beds and Related Equipment||05-15-2014||06-30-2015|
|Hospital Beds and Related Equipment||10-01-2008||05-14-2014|
|Hospital Beds and Related Equipment||04-15-2008||09-30-2008|
|Hospital Beds and Related Equipment||10-01-2006||04-14-2008|
|Hospital Beds and Related Equipment||07-15-2006||09-30-2006|
|Hospital Beds and Related Equipment||02-27-2004||07-14-2006|
|Hospital Beds and Related Equipment||08-01-2002||02-26-2004|