Hospital Bed Coverage Criteria
Fixed Height/Variable Height/Semi-Electric/Full Electric
A fixed height hospital bed (E0250, E0251, E0290, E0291) is covered if one or more of the following criteria (1-4) 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
- The beneficiary requires traction equipment, which can only be attached to a hospital bed.
A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.
A semi-electric hospital bed (E0260, E0261, E0294, E0295) is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.
A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.
Trapeze equipment (E0940) 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.
350lb Weight Cap
Hospital Bed Options
Half Rails
Standard Foam Mattress
Half Rails
Coverage for this accessory met with hospital bed criteria
Full Rails
Standard Foam Mattress
Half Rails
Coverage for this accessory met with hospital bed criteria
Standard Foam Mattress
Standard Foam Mattress
Group I Replacement Mattress
Coverage for this accessory met with hospital bed criteria
Group I Replacement Mattress
Group I Replacement Mattress
A Group 1 mattress overlay or mattress (E0181, E0184, E0185) is covered if one of the following three criteria are met:
- The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
- The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
- The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory perception
- Compromised circulatory status
Alternating Pressure Pad
A Group 1 mattress overlay or mattress (E0181, E0184, E0185) is covered if one of the following three criteria are met:
- The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
- The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
- The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory perception
- Compromised circulatory status
Gel Overlay
A Group 1 mattress overlay or mattress (E0181, E0184, E0185) is covered if one of the following three criteria are met:
- The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
- The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
- The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory perception
- Compromised circulatory status