Description

This document addresses the use of hospital beds, a specialty bed used primarily in the treatment of individuals with an illness or injury. Hospital bed accessories are durable medical equipment items used in conjunction with a hospital bed.

Policy

Hospital Beds

Medically Necessary:

A fixed height hospital bed is considered MEDICALLY NECESSARY if one or more of the following criteria are met:

1. The individual has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain, prevent contractures, promote good body alignment or avoid respiratory infections.

2. The individual 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 must have been considered and ruled out. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed.

3. The individual requires special attachments, such as traction equipment, that can only be attached to a hospital bed.

A variable height hospital bed is considered MEDICALLY NECESSARY if the individual meets one or more 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. This includes, but is not limited to:

1. Severe arthritis;

2. Fractured hips or other lower extremity injuries;

3. Spinal cord injuries;

4. Severe cardiac conditions;

5. Stroke.

A semi-electric hospital bed is considered MEDICALLY NECESSARY if the individual meets one or more of the criteria for a fixed height bed and requires frequent changes in body position or has an immediate need for a change in body position.

A heavy-duty, extra-wide hospital bed is considered MEDICALLY NECESSARY if the individual meets one or more of the criteria for a fixed height hospital bed and the individual’s weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed is considered MEDICALLY NECESSARY if the individual meets one or more of the criteria for a hospital bed and the individual’s weight exceeds 600 pounds.

An enclosed crib or enclosed bed is considered MEDICALLY NECESSARY for individuals with seizures, disorientation, vertigo, and neurological disorders, where the individual needs to be restrained to bed. Clinical documentation must be provided that states less invasive strategies (that is, bed rails, bed rail protectors, or environmental modifications) have been tried and have not been successful.

A request for a hospital grade, pediatric crib will be reviewed for MEDICALLY NECESSARY on an individual basis.

Not Medically Necessary:

If the above criteria are not met, the hospital bed will be considered NOT MEDICALLY NECESSARY.

A total electric hospital bed is considered NOT MEDICALLY NECESSARY. The height adjustment feature is considered to be a convenience feature. Ordinary (Non-Hospital) beds are considered NOT MEDICALLY NECESSARY.

An ordinary bed does not meet the definition of durable medical equipment as it is not primarily medical in nature and is not primarily used in the treatment of a disease or injury.

Power or manual lounge beds are considered NOT MEDICALLY NECESSARY since they are not primarily medical in nature and are considered to be a comfort or convenience item.

Bed Accessories

Medically Necessary:

Trapeze equipment is considered MEDICALLY NECESSARY if the individual is confined to bed and 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. Heavy duty trapeze equipment is considered MEDICALLY NECESSARY if the individual meets the criteria for regular trapeze equipment and weighs more than 250 pounds.

A bed cradle is considered MEDICALLY NECESSARY when it is necessary to prevent contact with the bed coverings. This includes, but is not limited to individuals with burns, decubitus or diabetic ulcers, or gouty arthritis.

Side rails or safety enclosures (such as, frame/canopy) are considered MEDICALLY NECESSARY when they are required by the individual’s condition and they are an integral part of, or an accessory to, a hospital bed.

If an individual’s condition requires a replacement innerspring mattress or foam rubber mattress it will be considered MEDICALLY NECESSARY for an individual-owned hospital bed.

Not Medically Necessary:

The following bed accessories are considered NOT MEDICALLY NECESSARY since they are not primarily medical in nature, are not mainly used in the treatment of a disease or injury and are normally of use to people who do not have a disease or injury:

1. Bedboards;

2. Overbed table;

3. Bed baths, bed spectacles, bed trays/reading tables, call switches, foot boards, bed lapboards;

4. Side rails when requested with a non-hospital or ordinary bed.

Side rails or frame/canopy for use with a hospital bed are considered NOT MEDICALLY NECESSARY when the above criteria are not met. Requests for bariatric beds for morbidly obese patients must include information regarding weight management. A hospital bed will not be approved for morbid obesity alone. Electrically powered adjustments to lower and raise the head and foot of the bed may be covered when:

• Medicaid determines that the patient’s condition requires a frequent change in body position.
• There may be an immediate need for a change in body position.
• The patient can operate the controls and cause the adjustments. Exceptions may be made in cases of spinal cord or brain injury. The documentation must indicate that the patient and/or caregiver can perform these changes in body positioning only using electric controls

Coding Section

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Hospital beds

When Services May Be Medically Necessary When Criteria Are Met:

HCPCS

E0250 – E0251 Hospital bed, fixed height, with any type side rails, with or without mattress

E0255 – E0256 Hospital bed, variable height, hi-lo, with any type side rails, with or without mattress E0260-E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with or without mattress

E0290 – E0291 Hospital bed, fixed height, without side rails, with or without mattress

E0292 – E0293 Hospital bed, variable height, hi-lo, without side rails, with or without mattress

E0294 – E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, with or without mattress

E0300 Pediatric crib, hospital grade, fully enclosed, with or without top enclosure

E0301 – E0304 Hospital bed, heavy duty/extra heavy duty (includes codes E0301, E0302, E0303, E0304) E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above the spring, includes mattress For the following code when specified as semi-electric:

E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above spring, includes mattress [specified as semi-electric]

ICD-10 Diagnosis All diagnoses

When Services Are Not Medically Necessary:

For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary

When Services Are Also Not Medically Necessary:

For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary

HCPCS

E0265 – E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with or without mattress

E0296 – E0297 Hospital bed, total electric, (head, foot and height adjustments), without side rails, with or without mattress For the following code when specified as total electric:

E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above spring, includes mattress [specified as total electric]

ICD-10 Diagnosis All diagnoses

Accessories

When Services May Be Medically Necessary When Criteria Are Met:

HCPCS

E0271 – E0272 Mattress

E0280 Bed cradle, any type

E0305 Bed side rails, half-length

E0310 Bed side rails, full-length E0316 Safety enclosure frame/canopy for use with hospital bed, any type

E0910 Trapeze bars, also known as Patient Helper, attached to bed, with grab bar

E0911 Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

ICD-10 Diagnosis All diagnoses

When Services Are Not Medically Necessary:

For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary

When Services Are Also Not Medically Necessary:

For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

HCPCS

E0273 Bed board

E0274 Over-bed table

E0315 Bed accessory: board, table or support device, any type

ICD-10 Diagnosis All diagnoses

Descriptions

A fixed-height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.

A variable-height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.

A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.

A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.

An ordinary bed is one that is typically sold as furniture. It consists of a frame, box springs and mattress. It is a fixed height and has no head or leg elevation adjustments. It is normally for use in the absence of illness or injury.

Power or manual lounge beds, like other ordinary beds, are typically sold as furniture and are not considered durable medical equipment as they are used in the absence of illness or injury. The following are examples of lounge beds:

1. Craftmatic^® Adjustable Bed;

2. Adjust-A-Sleep Adjustable Bed;

3. Electropedic^® Adjustable Bed (Electropedic Beds, Burbank, CA);

4. Simmons^® Beautyrest^® Adjustable Bed (Simmons Bedding Company, Norcross, GA);

5. Adjustable, vibrating beds.

The U.S. Food and Drug Administration (FDA) in 2005 determined that the Vail Enclosure Bed poses a significant public health risk because individuals can become entrapped and suffocate, resulting in severe neurological damage or death. Vail Products Inc. of Toledo, Ohio, has permanently ceased manufacture, sale and distribution of all Vail enclosed bed systems. The Centers for Medicare & Medicaid Services (CMS) criteria were used in the development of this document.

History From 2024 Forward

01/01/2024

New Policy