To be eligible for reimbursement, beds must meet the definition of durable medical equipment (DME) as follows:

1. The equipment must be able to withstand repeated use.
2. It must be primarily and customarily used to serve a medical purpose.
3. It should not be useful to a person in the absence of illness or injury.
4. The equipment should be appropriate for use in the home.

Hospital beds and others, such as air flotation and fluidized beds, meet this definition and are considered durable medical equipment. However, not all beds meet the definition of DME and therefore, are not eligible for reimbursement. Beds, as well as accessories and related items, should be processed in accordance with the guidelines on the Text Attachment below.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program.

PRN References

04/2006, Safety beds

MCIM 60-9, 60-19

Procedure Codes:

1. General Requirements

   A physician's prescription, and such additional documentation as the medical staff may consider necessary, including medical records and physicians' reports, must establish the medical necessity for a hospital bed due to one of the following reasons:
   

   1. 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;
   2. the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed.
   
   
2. Physician's Prescription

   The physician's prescription, which must accompany the initial claim, and supplementing documentation when required, must establish that a hospital bed is medically necessary. If the stated reason for the need for a hospital bed is 1.a. above, the prescription or other documentation must describe the medical condition, e.g., cardiac disease, chronic obstructive pulmonary disease, quadriplegia or paraplegia, and also the severity and frequency of the symptoms of the condition, that necessitates a hospital bed for positioning.

   If the stated reason for requiring a hospital bed is 1.b. above, the prescription must describe the patient's condition and specify the attachments that require a hospital bed.

3. Variable Height Feature

   In well documented cases, the medical staff may determine that a variable height feature of a hospital bed, approved for coverage under either 1.a. or b. above, is medically necessary and, therefore, covered, for one of the following conditions:
   

   1. Severe arthritis and other injuries to lower extremities, e.g., fractured hip, fractured spine. 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.
   2. Severe cardiac conditions. For those cardiac patients who are able to leave bed, but who must avoid the strain of "jumping" up or down.
   3. Spinal cord injuries or tumors, 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.
   4. Other severely debilitating diseases and conditions, if the variable height feature is required to assist the patient to ambulate; conditions such as, but not limited to the following:
   
   

   1. Advanced Cerebellar Degeneration
   2. Amyotrophic Lateral Sclerosis (ALS)
   3. Cancer (or Metastatic Ca) of the Lung
   4. Chronic Obstructive Lung Disease (COLD)
   5. Chronic Obstructive Pulmonary Disease (COPD)
   6. Demyelinating Diseases
   7. Musculoskeletal Diseases such as Muscular Dystrophy, Multiple Sclerosis
   8. Syringomyelia

Procedure Codes:

Hospital beds which electrically elevate and lower the head and foot of the bed are covered as durable medical equipment if the following criteria are met:

1. The patient meets the requirement for a standard hospital bed, (i.e., the patient requires positioning of the body not feasible in an ordinary bed or attachments are required which cannot be used on an ordinary bed).
2. The patient's condition requires frequent and/or immediate change in body position (i.e., no delay in change can be tolerated).
3. The patient can operate the controls himself.

When the patient's physician prescribes an electric hospital bed for one or more of the following conditions, the claim may be reimbursed:

1. Amyotrophic lateral sclerosis (ALS)
2. Bilateral amputee
3. Contractures (rigidity)
4. Fracture pelvis or spine
5. Paralysis (hemiparesis, hemiplegia, paraplegia, quadriplegia)
6. Pulmonary diseases such as:

   bronchial asthma accompanied by COLD or COPD
   bronchiectasis
   cancer (or metastatic cancer) of the lung
   emphysema
   chronic obstructive lung disease (COLD)
   chronic obstructive pulmonary disease (COPD)

7. Rheumatoid arthritis
8. Severe congestive heart failure
9. Severe neurological disorders such as:

   acquired (non Wilsonian) hepatocerebral degeneration
   advanced cerebellar degeneration
   amyotrophic lateral sclerosis
   cerebellar ataxia
   cerebral palsy
   CNS tumors/metastases
   Creutzfeldt-Jakob disease
   demyelinating diseases
   Huntington's disease
   multiple sclerosis
   muscular dystrophy
   myasthenia gravis
   parkinsonism (Parkinson's disease)
   poliomyelitis (and other myelitic syndromes, e.g., transverse myelitis)
   polyneuropathies/polyneuritis (toxic-ETOH; nutritional B-12 deficiency; Guillain-Barre syndrome)
   progressive multifocal leukoencephalopathy
   progressive supranuclear palsy
   spinal cord tumors
   spinal injuries resulting in paralysis
   spinal stenosis
   stroke (CVA)
   subacute sclerosing panencephalitis
   syringomyelia
   various ataxias (e.g., spastic ataxia paraparesis, Friedreich's ataxia)
   various dystonias (e.g., dystonia musculorum deformans)
   various leukodystrophies
   Wilson's disease

An electric hospital bed which is provided and/or prescribed because of the absence or inability of a person caring for the patient, for aesthetic reasons, or for added convenience is not eligible for reimbursement. Also, when an electric hospital bed is provided but is not prescribed by the patient's physician, the claim should be processed for the type of bed that was prescribed.

Any claim reporting diagnoses or conditions other than those mentioned above should be referred for medical review to determine the medical necessity for the hospital bed.

Full payment should not be made for a Franklin Electric Hospital bed. Payment should be based on whichever hospital bed above satisfies the patient's medical needs. In all cases, verify medical necessity for such features with the medical staff.

When the criteria are not met for an electric hospital bed, the claim will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Procedure Codes:

1. Powered Air Flotation Beds

   Covered when prescribed for patients in the third or fourth stages of decubitus ulceration and who otherwise meet all of the requirements for a standard hospital bed. Additionally, claims must include documentation from the prescribing physician which includes:
   

   1. the stage of ulceration
   2. the patient's prognosis
   3. the expected length of the treatment plan
   4. a statement that specifies the physician will be supervising the use of the bed during his course of treatment.
   
   Beds under the brand name of Flexicair should be denied as institutional equipment, inappropriate for home use. The appropriateness of all other brands of powered air flotation beds for use in the home must be established on an individual consideration basis.
   
   
2. Air-Fluidized Bed (Bead Bed)
   (Low Air Loss Therapy Beds, e.g., Orthoderm, Micro 1000, Tasi, Clini-Care Air Cushion Bed)

   An air-fluidized bed uses warm air under pressure to set small ceramic beads in motion which simulate the movement of fluid. When the patient is placed in the bed, his body weight is evenly distributed over a large surface area which creates a sensation of "floating."

   Payment for home use of an air-fluidized bed, procedure code E0194, for treatment of pressure sores can be made as durable medical equipment (DME) if such use is reasonable and necessary for the individual patient. Use of an air-fluidized bed may be considered reasonable and necessary when:
   

   1. The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore;
   2. The patient is bedridden or chair bound as a result of severely limited mobility;
   3. In the absence of an air-fluidized bed, the patient would require institutionalization;
   4. The air-fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success;
   5. A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage;
   6. A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; and
   7. All other alternative equipment has been considered and ruled out.
   
   
3. Oscillating Beds
   (Circoelectric Bed, Surgi-Bed, Vasculaider Bed, Vasocillating Bed)

   Oscillating beds are institutional equipment. They are not appropriate for home use, and as such, should be denied.

4. Fully Enclosed Pediatric Crib (E0300)

   A fully enclosed pediatric crib (manual or electric) is covered if determined to be medically necessary. Refer all claims for medical review.

5. Safety Beds (E1399)
   
   A safety bed (manual or electric) is covered for the primary indication of a patient's safety in the home if medical review determines that the patient's condition is so severe that they are prone to injury without use of the safety bed. Supporting medical documentation must be kept on file and be available upon request.
   
   Any claims for a safety bed not meeting the patient criteria will be denied on the basis that they do not meet the definition of DME (refer to Medical Policy Bulletin E-1). A participating, preferred, or network provider can bill the member for the denied service.