HOSPITAL BEDS and RELATED EQUIPMENT DME101.001 Bluereview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

COVERAGE:

HOSPITAL BEDS

Various types of hospital beds may be medically necessary when the selected appropriate criteria are met:

A. FIXED HEIGHT (one or more of the following is required):

· The patient requires positioning of the body for the alleviation of pain in ways not feasible with an ordinary bed.

· The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges should first have been considered.

· The patient requires traction equipment that can only be attached to a hospital bed.

B. VARIABLE HEIGHT (in addition to one of the fixed height criteria):

· The patient requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

C. SEMI-ELECTRIC:

· In addition to the all indications for A and B, the patient requires frequent or immediate changes in body position.

D. TOTAL ELECTRIC:

· This type of bed is rarely indicated EXCEPT in cases of spinal cord injuries, brain injury patients, and patients with neurological damage that prevents them from getting in or out of bed. These patients also require assistance with the basic activities of daily living (i.e., bathing, use of toilet).

E. HEAVY DUTY EXTRA WIDE:

· Is covered if the patient meets one of the criteria for a fixed height hospital bed and patient weight is more than 350 pounds but does not exceed 600 pounds.

Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

F. EXTRA HEAVY DUTY:

· Is covered if the patient meets one of the criteria for a hospital bed and the patient’s weight exceeds 600 pounds.

SPECIALTY BEDS

A. AIR FLUIDIZED:

Coverage will be allowed when ALL of the following guidelines are met:

· The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore.

· The patient is bedridden or chair bound as a result of limited mobility.

· In the absence of an air-fluidized bed, the patient would require institutionalization.

· Ordered by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after a course of conservative treatment designed to optimize conditions that promote wound healing. The evaluation must be performed within one month prior to initiation of therapy with the air fluidized bed.

· The course of conservative treatment must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation to verify that the necessary conservative treatment was rendered. Conservative treatment should include:

A. Frequent repositioning of the patient with particular attention to relief of pressure over prominences (usually every 2 hours);

B. Use of support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation;

C. Necessary treatment to resolve any wound infection;

D. Optimization of nutrition status to promote wound healing;

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

E. Debridement by any means, including wet to dry gauze dressings, to remove devitalized tissue from the wound bed;

F. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressing protected by an occlusive covering, while the wound heals;

G. Education of the patient/caregiver in the prevention and management of pressure ulcers;

H. Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly;

I. Appropriate management of moisture/incontinence.

· The availability of a trained adult caregiver to assist with activities of daily living, repositioning, skin care, fluid balance, dry skin care, recognition and management of altered mental status, dietary needs, prescribed treatments and management and support of the air-fluidized bed system and potential problems such as leakage.

· Physician directed home treatment regimen with ongoing physician directed assessment.

· All other alternative equipment has been considered and ruled out.

Home use of the air-fluidized bed is considered not medically necessary in the following circumstances:

· Presence of coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).

· Requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or occlusive material.

· Caregiver unwilling or unable to provide the type of care required by the patient on an air-fluidized bed.

· Structural support is inadequate to support the weight of the air-fluidized bed system (general weight 1,600 pounds or more.)

· Electrical system is insufficient for the anticipated increase in Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

energy consumption.

· Coverage limited to the equipment itself. Payment is not included for the caregiver or for architectural adjustments such as electrical or structural improvement.

· Other known contraindications exist.

B. POWER FLOATATION THERAPY BED/ALTERNATING PRESSURE SYSTEM

May be considered medically necessary if the patient meets one of the following combinations:

a. Criteria 1,2 & 3 or b. Criteria 4 or c. Criteria 5 & 6

CRITERIA

1. Multiple stage 2 pressure ulcers located on the trunk or pelvis.

2. 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.

3. The ulcers have worsened or remained the same over the past month.

4. Large or multiple stage 3 or 4 pressure ulcers on the trunk or pelvis.

5. 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.

6. Patient has been on an air fluidized bed or power air floatation bed immediately prior to a recent discharge from a hospital or nursing facility. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

C. INSTITUTIONAL BEDS:

Beds in this category may include,(but 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.

D. MISCELLANEOUS BEDS:

Beds such as the Craftmatic ® Adjustable bed and the Sleep Number bed by Select Comfort Corporation are not medically necessary as the features of these beds are not needed for the appropriate care and treatment of a patient and are not hospital beds.

RELATED EQUIPMENT

A. MATTRESS

Mattresses may be considered medically necessary only when the hospital bed is used as a whole unit or if replacement become necessary.

B. ALTERNATING PRESSURE MATTRESS AND PUMP OR GEL/WATER FLOATATION PAD:

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:

a. Criteria 1 b. Criteria 2 or 3 with at least one of criteria 4-7

Criteria:

1. Completely immobile (patient unable to make changes in body position without assistance).

2. Limited mobility (patient cannot independently make changes in body position enough to alleviate pressure) with.

3. Any stage pressure ulcer on the trunk or pelvis.

4. Impaired nutritional status.

5. Fecal or urinary incontinence.

6. Altered sensory perception. Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

7. Compromised circulatory status.

C. BED SIDE RAILS

Bed side rails may be considered medically necessary if required by the patient’s condition and they are an integral part of, or an accessory to a hospital bed. Some indications include but are not limited to:

· Confusion/disorientation; · Vertigo(dizziness); · Seizures; · Senile dementia or psychosis; · Senility.

D. BED CRADLE

Bed cradles may be considered medically necessary to prevent contact with bed coverings. Some indications include but are not limited to:

· Burns, · Gangrene of the feet, and · Impaired circulation in the feet.

E. TRAPEZE BARS

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.

F. BED BOARDS AND OVER THE BED TABLES

These items are not a covered benefit as they are considered convenience items.

G. SAFETY NET ENCLOSURE

This is safety netting over a frame/canopy for use with a hospital bed to prevent falls. This item is not a covered benefit as its use is for institutional facilities only.

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

DOCUMENTATION

The patient's medical record must contain documentation substantiating their condition meets the above criteria. ______DESCRIPTION:

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.

Hospital beds may be:

· A fixed height hospital bed is one with manual head and leg elevation adjustments but not bed height adjustment.

· A variable height hospital bed is one with manual height adjustments and with electric head and leg elevation adjustments.

· A semi-electric hospital bed is one with manual height adjustment and electric head and leg adjustments.

· A total electric hospital bed is one with electric height adjustments and electric head and leg adjustments. The additional feature allowing for motorized adjustment of the height of the bed frame from the floor is strictly for the convenience of the caregiver. The caregiver may have physical limitations in his/her ability to care for the patient.

· A heavy duty extra wide is a hospital bed capable of supporting a patient weight between 350 and 600 pounds.

· An extra heavy duty bed is a bed is able to support patient weight more than 600 pounds.

· An air fluidized therapy bed is a device employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of fluid. Uses include:

A. Treatment and/or prevention of decubitus ulcers, B. Management of severe to extensive burns, and C. Aid in circulation.

· A powered floatation therapy bed is a semi electric or total electric hospital bed with a fully integrated powered pressure Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company* Southwest Texas HMO, Inc.* d/b/a HMO BlueÒ Texas * Independent Licensees of the Blue Cross and Blue Shield Association

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

reducing mattress, containing a large volume of constantly moving water, air or sand. Uses include:

A. Treatment and/or prevention of decubitus ulcers, B. Management of severe to extensive burns, and C. Aid in circulation.

Miscellaneous 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. ______RATIONALE:

None ______PRICING:

If the projected cost of renting hospital beds or related equipment for temporary conditions exceeds the cost of purchasing the equipment, reimbursement should never exceed the purchase price.

If the cost of repair exceeds the cost of purchasing a new item or renting the item for the remaining period of medical need, the most cost-effective alternative should be chosen. ______REFERENCES:

HOSPITAL BEDS AND RELATED EQUIPMENT DME101.001 BlueReview POSTED DATE: 11/17/2003 EFFECTIVE DATE: 2/27/2004 ______

· Strauss, M.J., et al. “The Cost Home Air-Fluidized Therapy for Pressure Sores.” Journal of Family Practice (1991 July) 33(1): 52- 59 · Nimit, K. Guidelines for Home Air-Fluidized Therapy. Health Technology Assessments (1989) 5:1-11 Medline Oct. 1992 Perez, E. David M.D. “Updated Guidelines for Treatment and Prevention.” Geriatrics 1993 48:39-44 · DMERC Manual “Pressure Reducing Support Surfaces Group 1 Chapter 32.” (2000) http://www.palmettogba.com/palmetto/providers.nsf/(Docs)/85256CF400 62C0E9852566C DMERC Manual “Pressure Reducing Support Surface Group 2 Chapter 33.” (2000) http://www.palmettogba.com/palmetto/providers.nsf/PrintableDocs/852 56CF40062C0E98 · DMERC Manual “Pressure Reducing Support Surfaces Group 3 Chapter 33.” (2000) http://www.palmettogba.com/palmetto/providers.nsf/(DOCS)/85256CF400 62C0E9852566C ______DISCLAIMER:

State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, takes precedence over Medical Policy and must be considered first in determining coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Any benefits are subject to the payment of premiums for the date on which services are rendered. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically. HMO Blue Texas physicians who are contracted/affiliated with a capitated IPA/medical group must contact the IPA/medical group for information regarding HMO claims/reimbursement information and other general polices and procedures.