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; 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 _____________________________________________________________________________ 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,