Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Pressure-Reducing Support Surfaces

Policy #:05.00.60g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Pressure-reducing support surfaces are considered medically necessary and, therefore, covered for individuals who are at high risk for developing, or have developed, pressure ulcers. The medical necessity criteria for each device group is defined below. The support surface provided should be one in which the individual does not "bottom out." Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the mattress overlay or mattress and the individual's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the individual in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the side-lying position.

GROUP 1

MEDICALLY NECESSARY
Group 1 mattress overlay or mattress (HCPCS codes A4640, E0181-E0187, E0196-E0199) is medically necessary when the individual meets one or more of the following criteria:
  • The individual is completely immobile (i.e., cannot make changes in body position without assistance).
  • The individual experiences any one of the following: altered sensory perception, compromised circulatory status, impaired nutritional status, and/or incontinence (urinary or fecal), along with one of the following:
    • Limited mobility (i.e., cannot independently make changes in body position significantly enough to alleviate pressure)
    • A pressure ulcer (any stage) on the trunk or pelvis

NOT MEDICALLY NECESSARY
All other uses for Group 1 pressure-reducing support surfaces are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.

GROUP 2

MEDICALLY NECESSARY
A Group 2 support surface is considered medically necessary when the individual meets one or more of the following criteria:
  • The individual has multiple stage II pressure ulcers on their trunk or pelvis and all of the following:
    • They have been on a comprehensive ulcer treatment program. This program should generally include the following components:
      • Education of the individual and caregiver on the prevention and/or management of pressure ulcers
      • Regular assessment by a licensed health care professional (usually at least weekly for an individual with a stage III or IV ulcer)
      • Appropriate turning and positioning
      • Appropriate wound care (for a stage II, III, or IV ulcer)
      • Appropriate management of moisture/incontinence
      • Nutritional assessment and intervention consistent with the overall plan of care
    • Placed on an appropriate Group I support surface, for a duration of four weeks
    • The ulcer is not healing or has worsened over the four weeks
  • The individual has large or multiple stage III or IV ulcer(s) on their trunk or pelvis.
  • The individual received a myocutaneous flap or skin graft within the past 60 days to treat a pressure ulcer on their trunk or pelvis and was on a Group 2 or 3 support surface within the past 30 days prior to being discharged from a hospital or nursing facility.
    • Coverage is generally limited to 60 days from the date of surgery.

Group 2 codes include the following:

A low-air-loss bed (E0193) is considered medically necessary when the individual meets the criteria for a Group 2 support surface and bottoms out on an advanced nonpowered mattress, a powered air overlay, and a powered mattress.

A powered mattress (E0277) is considered medically necessary when the individual meets the criteria for a Group 2 support surface and bottoms out on a powered air overlay and advanced nonpowered mattress.

An advanced nonpowered mattress (E0373) is considered medically necessary when the individual meets the criteria for a Group 2 support surface and bottoms out on an advanced nonpowered overlay and powered air overlay.

A powered air overlay (E0372) is considered medically necessary when the individual meets the criteria for a Group 2 support surface and bottoms out on an advanced nonpowered overlay.

An advanced nonpowered overlay (E0371) is considered medically necessary when the individual meets the criteria for a Group 2 support surface.

Continued use of a Group 2 support surface is considered medically necessary when the individual meets one of the following criteria:
  • Until the ulcer is healed.
  • If healing does not continue, the treating licensed health care provider documents that the continued use of a Group 2 support surface is medically necessary for wound management, or other aspects of the care plan are adjusted to promote wound healing.

NOT MEDICALLY NECESSARY
All other uses for a Group 2 pressure-reducing support surface are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

GROUP 3

MEDICALLY NECESSARY
A Group 3 air-fluidized bed (E0194) is considered medically necessary when the individual meets all of the following criteria:
  • The individual is bedridden or chair bound as a result of severely limited mobility.
  • The individual has stage III or IV pressure ulcers.
  • The individual has failed Group II support surfaces (i.e., after more than four weeks, the ulcers are worsening or not healing).
  • The air-fluidized bed was prescribed by the treating licensed healthcare provider after a comprehensive assessment and evaluation, within one month of a request to initiate a Group 3 support surface, and after a course of conservative treatment of at least one month that is designed to optimize wound healing, and includes all of the following:
    • Frequent repositioning of the individual to relieve pressure over bony prominences (usually every two hours)
    • Use of a group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation
    • Any necessary treatment to resolve an existing wound infection
    • Optimization of nutritional status to promote wound healing
    • Debridement by any means (including wet-to-dry gauze dressings), if needed, to remove devitalized tissue from the wound bed
      • Wet-to-dry dressings when used for debridement do not require an occlusive dressing. Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days, will not preclude coverage of an air-fluidized bed. Should additional debridement again become necessary while a patient is using an air-fluidized bed (after the first 30-day course of conservative treatment), that will not cause the air-fluidized bed to be denied.
    • Maintenance of a clean, moist bed of granulating tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals
      • An occlusive barrier is required, when necessary, to maintain a moist wound-healing environment that may otherwise be compromised by the drying action of airflow generated by air-fluidized therapy. If moist dressings are NOT required because of the wound characteristics (e.g., heavily exudative wound, etc.), the occlusive barrier is not required as a condition for reimbursement.
    • Additionally, conservative treatment may include the following components:
      • Education of the individual and caregiver on the prevention and management of pressure ulcers
      • Assessment by a licensed health care professional at least weekly
      • Appropriate management of moisture/incontinence
  • A healthcare professional--directed home treatment regimen that includes a monthly re-evaluation of the need for an air-fluidized bed.
  • The individual would require institutionalization in the absence of an air-fluidized bed.
  • The individual's home environment can accommodate the equipment.
  • A trained adult caregiver is able and willing to provide the type of care the individual requires with the use of an air-fluidized bed (e.g., assistance with activities of daily living, repositioning, dietary needs, fluid balance, skin care, prescribed treatments, recognition and management of altered mental status) and in use/management of the air-fluidized bed and its problems such as leakage.
  • The individual has no contraindications related to the use of an air-fluidized bed (e.g., coexisting pulmonary disease [the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions]).

Continued use of a Group 3 support surface is considered medically necessary when the licensed health care professional documents the necessity for the Group 3 support surface on a monthly basis (including the size of the ulcer; the aspects of the care plan being adjusted to promote wound healing; and continued use of the bed being necessary for wound management); and one of the following criteria are met:
  • Until the ulcer is healed.
  • If healing does not continue, the treating licensed health care professional documents that the continued use of a Group 3 support surface is medically necessary for wound management, or other aspects of the care plan are adjusted to promote wound healing.

NOT MEDICALLY NECESSARY
All other uses for an air fluidized bed (E0194), including the conditions listed below, are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the treatment of illness or injury.
  • The individual has co-existing pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).
  • The individual requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or occlusive material.
  • The caregiver is unwilling or unable to provide the type of care required by the member on air-fluidizing bed.
  • The structural support is inadequate to support the weight of the air-fluidized bed system (approximately 1600 lbs or more).
  • The electrical system is insufficient for the anticipated increase in energy consumption.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

The reimbursement for the item(s) represented by the code(s) in column II are included in the reimbursement for the item represented by the code in column I.

Column I Column II
E0181 A4640, E0182


FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

E0185 GEL OR GEL-LIKE PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0197 AIR PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0198 WATER PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0199 DRY PRESSURE PAD FOR MATTRESS, STANDARD MATTRESS LENGTH AND WIDTH
E0194AIR FLUIDIZED BED


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

Documentation of a face to face encounter, between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s) must be provided to and kept on file by the DME supplier.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Guidelines

An individual who needs a pressure-reducing support surface should have a documented care plan that was established by a licensed health care professional. Treatment includes, but is not limited to:
  • Wound care appropriate to the stage of the ulcer
  • Nutritional assessment with the provision of an adequate diet and/or nutritional supplements
  • Frequent positioning
  • Management of incontinence
  • Education for the individual and caregiver on ulcer prevention and/or treatment
  • Regular assessment by a licensed health care professional (usually at least weekly for an individual with a stage III or IV ulcer)

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, pressure support surfaces are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The US Food and Drug Administration (FDA) has approved numerous devices for the use of pressure-reducing support surfaces.

Description

A pressure ulcer, also referred to as decubitus ulcer, pressure sore, or bedsore, is defined as an area of localized tissue necrosis caused by soft tissue being compressed between a bony prominence and an external surface. Pressure ulcers usually occur over bony prominences and are staged to classify the degree of tissue damage observed. If eschar is present, a pressure ulcer cannot be accurately staged until the eschar is removed. A nonhealing wound is one in which all appropriate wound management treatments have been explored but has not changed or improved in appearance or has increased in size or depth.

The staging of pressure ulcers is as follows:
  • Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, or warmer or cooler as compared to adjacent tissue.
  • Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
  • Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. The pressure ulcer may also present as an intact or open/ruptured serum-filled blister.
  • Stage III: Full thickness tissue loss. Subcutaneous fat may be visible in the pressure ulcer, but bone, tendon or muscle is not exposed. Slough may be present, but it does not obscure the depth of tissue loss. Undermining and tunneling may also be present.
  • Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Undermining and tunneling are often present.
  • Unstageable: Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound.

A pressure-reducing support surface is a device (i.e., overlay, mattress, bed) that reduces or eliminates tissue interface pressure to help prevent ulcer formation in individuals who are completely immobile (i.e., cannot make changes in body position without assistance) or have limited mobility (i.e., cannot independently make changes in body position significantly enough to alleviate pressure). The device conforms to the contours of the body so that the pressure is distributed over a larger surface area, causing reduced or eliminated interface pressure.

PRESSURE-SUPPORT SURFACE GROUPS

Pressure-reducing support surface devices are divided into the following three groups, which is consistent with Medicare's categorization:

GROUP 1
  • A nonpowered overlay is a pad placed on top of a standard mattress that is made from synthetic sheepskin or lamsbwool or composed of cells that may be filled with gel, air, water, or foam. The cells distribute pressure uniformly over the support area. A gel or foam overlay has a height of 2 inches or greater. An air or water overlay has a height of 3 inches or greater.
  • A powered overlay is a pad placed on top of a standard mattress that uses an air pump or blower to inflate or deflate the cells or to circulate air throughout the cells. The cell height is 2.5 inches or greater.
  • A nonpowered mattress is a foam, air, water, or gel mattress that can be placed on a hospital bed frame and has a height of at least 5 inches and a waterproof cover.

GROUP 2
  • An advanced nonpowered overlay is a pad placed on top of a standard mattress that provides more pressure reduction than a Group 1 nonpowered overlay. The overlay has a total height of 3 inches or greater, and has friction or shear reduction qualities.
  • An advanced nonpowered mattress is a mattress that provides more pressure reduction than a Group 1 mattress, can be placed on a hospital bed frame, has a total height of 5 inches or greater, and is designed to decrease friction or shear.
  • A powered mattress is an alternating pressure mattresses or low air loss mattress placed on a standard hospital bed frame that uses an air pump or blower to inflate or deflate the cells or circulate air throughout the cells of the mattress. The mattress has a total height of 5 inches or greater, and is designed to decrease friction or shear.
  • A low-air-loss bed is a semi-electric or electric bed with an integrated powered mattress. The mattress consists of a series of interconnected woven fabric air pillows that allow some air to escape through the surfaces. The pillows can be variably inflated to adjust the level of pressure relief.
  • A powered mattress overlay is an overlay with low air loss; powered flotation without low air loss; or alternating pressure. The overlay has an inflated height of 3.5 inches or greater.

GROUP 3
  • An air-fluidized bed uses a high rate of air flow to fluidize fine particulate material (e.g., sand, silicone-coated ceramic beads) to simulate the characteristics of fluid.

References


Berlowitz D. Clinical staging and management of pressure-induced injury
Last updated: July 16, 2018. In: UpToDate, Available at: http://www.uptodate.com/contents/clinical-staging-and-management-of-pressure-induced-injury [subscription may be required]. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Pressure Reducing Support Surfaces - Group 1 Policy Article (A52489). Original effective: 10/01/15. Revised effective: 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+1. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Pressure Reducing Support Surfaces - Group 2 Policy Article (A52490). Original effective: 10/01/15. Revised effective: 05/25/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+2. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Pressure Reducing Support Surfaces - Group 3 Policy Article (A52468). Original effective: 10/01/15. Revised effective: 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+3. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Pressure Reducing Support Surfaces- Group 1. Local Coverage Determination (LCD). (L33830). Original effective: 10/01/15. Revised effective: 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+1. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). (L33642): Pressure reducing support surfaces- Group 2. Original effective: 10/01/15. Revised effective: 05/25/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+2. Accessed September 14, 2018.

Noridian Healthcare Solutions, LLC. Pressure Reducing Support Surfaces- Group 3. Local Coverage Determination (LCD). (L33692): Original effective: 10/01/15. Revised effective: 01/01/2017. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/PRSS+Group+3. Accessed September 14, 2018.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment A for a list of diagnoses.


HCPCS Level II Code Number(s)



MEDICALLY NECESSARY

GROUP 1 PRESSURE REDUCING SUPPORT SURFACES

A4640 Replacement pad for use with medically necessary alternating pressure pad owned by patient

E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182 Pump for alternating pressure pad, for replacement only

E0184 Dry pressure mattress

E0185 Gel or gel-like pressure pad for mattress, standard mattress length and width

E0186 Air pressure mattress

E0187 Water pressure mattress

E0196 Gel pressure mattress

E0197 Air pressure pad for mattress, standard mattress length and width

E0198 Water pressure pad for mattress, standard mattress length and width

E0199 Dry pressure pad for mattress, standard mattress length and width


GROUP 2 PRESSURE REDUCING SUPPORT SURFACES

E0193 Powered air flotation bed (low air loss therapy)

E0277 Powered pressure-reducing air mattress

E0371 Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width

E0372 Powered air overlay for mattress, standard mattress length and width

E0373 Nonpowered advanced pressure reducing mattress


GROUP 3 PRESSURE REDUCING SUPPORT SURFACE

E0194 Air-fluidized bed



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Pressure-Reducing Support Surfaces
Description: ICD-10 Codes




Policy History

05.00.60g
11/26/2018This version of the policy will become effective 11/26/2018.

The intent of this policy has not changed, although it has been modified to incorporate the following ICD-10 CM codes and HCPCS code.

The following ICD-10 CM codes have been added to Attachment A of this policy:

L89.003, L89.004, L89.013, L89.014, L89.023, L89.024, L89.200, L89.201, L89.202, L89.203, L89.204, L89.209, L89.300, L89.301, L89.302, L89.303, L89.304, L89.309, L89.503, L89.504, L89.513, L89.514, L89.523, L89.524, L89.603, L89.604, L89.613, L89.614, L89.623 L89.624, L89.813, L89.814, L89.893, L89.894, L89.93, L89.94

The following HCPCS codes have been deleted from this policy:

E0188 Synthetic sheepskin pad
E0189 Lambswool sheepskin pad, any size


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 11/26/2018
Version Issued Date: 11/26/2018
Version Reissued Date: N/A

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