Hospital Beds (NCD 280.7) – Medicare Advantage Policy Guideline
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UnitedHealthcare® Medicare Advantage Policy Guideline Hospital Beds (NCD 280.7) Guideline Number: MPG144.07 Approval Date: June 9, 2021 Terms and Conditions Table of Contents Page Related Medicare Advantage Policy Guidelines Policy Summary ............................................................................. 1 • Air-Fluidized Bed (NCD 280.8) Applicable Codes .......................................................................... 3 • KX Modifier Definitions ...................................................................................... 6 • Pressure Reducing Support Surfaces References ..................................................................................... 7 • Durable Medical Equipment Reference List (NCD Guideline History/Revision Information ....................................... 8 280.1) Purpose .......................................................................................... 8 Terms and Conditions ................................................................... 9 Related Medicare Advantage Reimbursement Policy • Durable Medical Equipment Charges in a Skilled Nursing Facility Policy Related Medicare Advantage Coverage Summary • Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Policy Summary See Purpose Overview A physician's prescription and additional documentation, including medical records and physicians' reports, must establish the medical necessity for a hospital bed due to one of the following reasons: The patient's condition requires positioning of the body; e.g., to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, in ways not feasible in an ordinary bed; or The patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. Guidelines For the items addressed in this policy, the "reasonable and necessary" criteria, based on Social Security Act §1862(a) (1) (A) provisions, are defined by the following indications, limitations and/or medical necessity. For any item to be covered by Medicare, it must Be eligible for a defined Medicare benefit category, Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and Meet all other applicable Medicare statutory and regulatory requirements. A fixed height hospital bed is covered if one or more of the following criteria are met: The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or The beneficiary 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, or Hospital Beds (NCD 280.7) Page 1 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 06/09/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. The beneficiary requires traction equipment, which can only be attached to a hospital bed. Variable Height Feature UnitedHealthcare may determine that a variable height feature of a hospital bed is medically necessary and, therefore, covered, for one of the following conditions: Severe cardiac conditions. For those cardiac patients who are able to leave bed, but who must avoid the strain of "jumping" up or down; Severe arthritis and other injuries to lower extremities; e.g., fractured hip. The condition requires the variable height feature to assist the patient to ambulate by enabling the patient to place his or her feet on the floor while sitting on the edge of the bed; Spinal cord injuries, including quadriplegic and paraplegic patients, multiple limb amputee and stroke patients. For those patients who are able to transfer from bed to a wheelchair, with or without help; or Other severely debilitating diseases and conditions, if the variable height feature is required to assist the patient to ambulate. Electric powered adjustments to lower and raise head and foot may be covered when the UnitedHealthcare medical staff determines that the patient's condition requires frequent change in body position and/or there may be an immediate need for a change in body position (i.e., no delay can be tolerated) and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients. A heavy duty extra wide hospital bed is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary’s weight is more than 350 pounds, but does not exceed 600 pounds. An extra heavy-duty hospital bed is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary’s weight exceeds 600 pounds. A total electric hospital bed is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. If the beneficiary does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary. Accessories Trapeze equipment is covered if the beneficiary needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. Trapeze bars attached to a bed are noncovered when used on an ordinary bed. Heavy duty trapeze equipment is covered if the beneficiary meets the criteria for regular trapeze equipment and the beneficiary’s weight is more than 250 pounds. A bed cradle is covered when it is necessary to prevent contact with the bed coverings. Side rails or safety enclosures are covered when they are required by the beneficiary’s condition and they are an integral part of, or an accessory to, a covered hospital bed. If a beneficiary’s condition requires a replacement innerspring mattress or foam rubber mattress it will be covered for a beneficiary owned hospital bed. A bed board is non-covered since it is not primarily medical in nature. An over bed table is non-covered because it is not primarily medical in nature. Documentation Requirements – General There are numerous CMS manual requirements, reasonable and necessary requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Refer to the LCD, NCD, or other CMS Manuals for more information on what documents may be required. See Article A55426 Standard Documentation Requirements for All Claims Submitted to DME MACs. Hospital Beds (NCD 280.7) Page 2 of 9 UnitedHealthcare Medicare Advantage Policy Guideline Approved 06/09/2021 Proprietary Information of UnitedHealthcare. Copyright 2021 United HealthCare Services, Inc. Applicable Codes The following list(s) of codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply. HCPCS Code Description E0193 Powered air flotation bed (low air loss therapy) Fixed Height Beds E0250 Hospital bed, fixed height, with any type side rails, with mattress E0251 Hospital bed, fixed height, with any type side rails, without mattress E0290 Hospital bed, fixed height, without side rails, with mattress E0291 Hospital bed, fixed height, without side rails, without mattress E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress Variable Height Beds E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress Semi - Electric Beds E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress Total Electric Beds E0265 Hospital bed, total electric (head, foot and height adjustments), with any type side rails, with mattress (Not covered) E0266 Hospital bed, total electric (head, foot and height adjustments), with any type side rails, without mattress (Not covered) E0296 Hospital bed, total electric