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HealthPartners

Coverage criteria policies

Pressure reducing support surfaces

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Requires prior authorization except when requested for a member enrolled in a hospice program.

Coverage

Pressure reducing support surfaces are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Pressure reducing support surfaces are a type of durable medical equipment (DME) used for care of pressure injuries, also known as pressure sores or ulcers. Pressure injuries are lesions caused by unrelieved pressure which results in damage of underlying tissue. Pressure reducing support surfaces are categorized into three groups. A major distinction between support surfaces is that some are powered by electricity and others are not. Coverage criteria for each group are listed separately below.

A Group I support surface (E0181, E0182, E0184, E0185, E0186, E0187, E0196, E0197, E0198, E0199, and A4640) may be eligible for coverage when used as part of a comprehensive, documented pressure injury treatment plan and the following criteria are met:

Criterion 1, or
Criterion 2 or 3 and at least one of the conditions listed in criteria 4 through 7

  1. The member is completely immobile (cannot make changes in body position without assistance)
  2. The member has limited mobility (cannot independently make changes in body position that are significant enough to alleviate pressure)
  3. The member has any stage pressure injury on the trunk or pelvis
  4. Impaired nutritional status
  5. Fecal or urinary incontinence
  6. Altered sensory perception
  7. Compromised circulatory status

Indications that are not covered for a Group I surface

An egg crate mattress is not covered for those members not enrolled in a hospice program because it is considered household equipment or a comfort/convenience item.

A Group II support surface (E0193, E0277, E0371, E0372, and E0373) may be eligible for coverage when used as part of a comprehensive, documented pressure injury treatment plan and the following criteria are met:

Criterion 1 and 2 and 3, or
Criterion 4, or
Criterion 5 and 6

  1. The member has multiple stage 2 pressure injuries on the trunk or pelvis.
  2. The member has been on a comprehensive ulcer treatment plan for at least the past 30 days which included the use of an appropriate Group I support surface.
  3. The pressure injuries have remained the same or worsened over the past 30 days.
  4. The member has large or multiple stage 3 or 4 pressure injuries on the trunk or pelvis.
  5. A myocutaneous flap or skin graft procedure has been performed within the past 60 days for a pressure injury on the trunk or pelvis.
  6. The member has been on a Group II or III support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

Note: Continued use of a Group II support surface is covered until the injury is healed. If healing does not continue, there must be documentation in the medical record to demonstrate that other aspects of the care plan are being modified to promote healing or that the use of the Group II surface is medically necessary for wound management.

A Group III support surface (E0194) may be eligible for coverage when used as part of a comprehensive, documented pressure injury treatment plan and all of the following criteria are met:

  1. The member has a Stage 3 or Stage 4 pressure injury.
  2. The member is bedridden or chair bound as a result of severely limited mobility.
  3. The member would require institutionalization in the absence of an air-fluidized bed.
  4. The air-fluidized bed is ordered based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success for a minimum of 30 days. The evaluation generally must be performed within a week prior to initiation of therapy with the air-fluidized bed. Documentation must include that the following components have been included in the conservative treatment plan:
    1. Education of the patient and caregiver on the prevention and/or management of pressure injuries.
    2. Assessment by a physician, nurse, or other licensed health care practitioner at least weekly.
    3. Appropriate turning and positioning.
    4. Use of a Group II support surface, if appropriate.
    5. Appropriate wound care.
    6. Appropriate management of moisture/incontinence.
    7. Nutritional assessment and intervention consistent with the overall plan of care.
  5. A trained adult caregiver is available to assist the member with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments and management/support of the air-fluidized bed system including potential problems, such as leakage.
  6. A physician directs the home treatment regimen, including reevaluating and recertifying the need for the air-fluidized bed on a monthly basis.
  7. All other alternative equipment has been considered and ruled out.

Continued use of a Group III support surface is covered until the injury is healed. If healing does not continue, there must be documentation in the medical record to demonstrate that other aspects of the care plan are being modified to promote healing or that the use of the Group III surface is medically necessary for wound management.

Indications that are not covered for Group III surfaces

  1. The member has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).
  2. The member requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering, such as plastic wrap or other occlusive material.
  3. The structural support of the home is inadequate to support the weight of the air-fluidized bed system.
  4. The existing electrical system is insufficient for the anticipated increase in energy consumption.

Definitions

Group I support surface: A pressure reducing mattress overlay or mattress designed to be placed on top of a standard hospital bed or home mattress. It may be non-powered or powered. This category includes coverings which are high density foam, gel, air or water filled, alternating pressure, or low air loss.

Group II support surface: A powered, pressure reducing mattress overlay or replacement mattress (alternating pressure or low air loss). This surface works by inflating cells or tubes with air.

Group III support surface: An air-fluidized bed which uses warm air, under pressure, to set silicone coated ceramic beads in motion. This simulates the movement of fluid. When the patient is in this bed, the body weight is evenly distributed over a large surface area which creates a sensation of floating.

Stage I Injury: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.

Stage 2 Injury: Partial thickness loss of skin presenting as a shallow open wound with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Stage 3 Injury: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed or directly palpable. Slough may be present but not obscure the depth of tissue loss. May include undermining or tunneling. Depth may vary by anatomical location.

Stage 4 Injury: Full thickness tissue loss with exposed bone, tendon, or muscle that is visible or directly palpable. Slough or eschar (dry, dark scab or falling away of dead skin) may be present on some parts of the wound bed. Rolled wound edges and undermining/tunneling are often present. Depth varies by anatomical location. Can extend into muscle or supporting structures.

Unstageable: Full thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is obscured by slough and/or eschar (dry, dark scab or falling away of dead skin).

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Code

Description

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

E0193

Powered air flotation bed (low air loss therapy)

E0194

Air fluidized bed

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

E0277

Powered pressure-reducing air mattress

E0370

Air pressure elevator for heel

E0371

Non-powered advanced pressure reducing overlay for mattress, standard mattress length and width

E0372

Powered air overlay for mattress, standard mattress length and width

E0373

Non-powered advanced pressure reducing mattress

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • Items must be received from a contracted vendor for In-Network benefits to apply

References

  1. Berlowitz, D. Prevention of pressure-induced skin and soft tissue injury. In: UpToDate, Schmader, K. and Sanfey, H. (Ed), UpToDate, Waltham, MA. (Accessed May, 17, 2017).
  2. Berlowitz, D. Clinical staging and management of pressure-induced skin and soft tissue injury. In: UpToDate, Sanfey, H. and Schmader, D. (Ed), UpToDate, Waltham, MA. (Accessed May, 17, 2017).
  3. ECRI Institute. (2016). Hotline Response-Therapeutic Support Surfaces for Preventing and Treating Pressure Ulcers. Plymouth Meeting, PA: ECRI Institute.
  4. Hayes, Inc. Hayes Medical Technology Directory Report. Pressure-Reducing Support Surfaces for Pressure Ulcers. Lansdale, PA: Hayes, Inc.; May, 2010. Reviewed June, 2014/Archived June/2015.
  5. McInnes, E., Jammali-Blasi, A., Bell-Sayer SEM, Dumville, J., Middleton, V. and Cullum, N. (2015) Support Surfaces for pressure ulcer prevention (Review). Cochrane Database for Systematic Reviews. Retrieved from https://www.cochranelibrary.com on 5/17/17.
  6. National Pressure Ulcer Advisory Panel (NPUAP). (2016). National Pressure Ulcer Advisory Panel announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. Retrieved from https://npuap.org on 4/21/2016).
  7. Ratliff, C., Droste, L., Bonham, P.Crestodina, L. Johnson, J. Kelechi, T. Varnado, M….and Palmer, R. (2016) Wound, Ostomy, and Continence Nurses Society 2016 Guideline for Prevention and Management of Pressure Injuries(Ulcers): An Executive Summary. Journal of Wound, Ostomy and Continence Nursing. 44(3). May/June2017, p241-246.
  8. National Institute for Health and Care Excellence (2014). Pressure Ulcers: prevention and management. Clinical Guideline. Retrieved from https://www.nice.org.uk/ on 5/17/17.
  9. Reddy, M., Gill, S. and Rochon, P. (2006). Preventing Pressure Ulcers: A Systematic Review. JAMA. 296(8): 974-984.
  10. Thomas, D. R. (2016). Pressure Ulcers. Conn’s Current Therapy. (1): 957-959.