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Coverage criteria policies

Hospital Bed

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

Administrative Process

Clinics should direct members to contact a contracted DME vendor to order the item.

Prior authorization is not required for rental items for members enrolled in a hospice program.

For all other members:

  • Prior authorization is required starting with the fourth (4th) month of rental and prior to the purchase of the item.
  • Vendors must submit a request for prior authorization for the fourth month of rental of the item using the Durable Medical Equipment (DME) Vendor Prior Authorization Form (please see related content at right for document), including any supporting clinical information available.

Rentals longer than three months and purchases are subject to all of the criteria and documentation requirements noted in this policy and require prior authorization.

Equipment used in skilled nursing facilities (SNF) or long term care (LTC) requires prior authorization – Please see related content at the right for link to “equipment in skilled nursing/long term care facility” for coverage.

Coverage

Generally covered subject to the indications listed below and the following limits from your member contract:

Indications that are covered

  1. General Requirements for Coverage of Hospital Beds (including fixed height hospital bed, variable height hospital bed, semi-electric hospital bed, total electric hospital bed, pediatric safety bed, heavy duty extra wide hospital bed and extra heavy duty hospital bed): A physician's prescription and such additional documentation as the contractors' medical staffs 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); or
    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 the patient's condition requires positioning, 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 the patient's condition requires special attachments, the prescription must describe the patient's condition and specify the attachments that require a hospital bed.
  3. Medical condition requires features of a hospital bed (height adjustment, head and foot adjustments) or special attachments, which are not available for use with ordinary beds. Evaluation will include review of diagnosis, severity, and frequency of symptoms. The following is a list, though not all inclusive, of examples:
    1. Medical condition requires frequent changes in positions (i.e., every 1-2 hours or more frequently).
    2. Medical condition may require immediate changes in position (i.e., no delay can be tolerated, such as with potential aspiration or severe respiratory problems).
    3. Medical condition requires positioning of the body, such as to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections, etc.
    4. Evaluation will include review of diagnosis, severity and frequency of symptoms.
    5. Medical condition would be adversely affected by strain of transfers.
    6. Severe debilitating condition requiring bed adjustments for transfers.
    7. The patient’s condition requires special attachments that cannot be fixed and used on an ordinary bed.
Covered Accessories – No prior authorization required. Only covered when used with a covered hospital bed
  1. Trapeze equipment (E0910, E0940 - regular; E0911 & E0912 – heavy duty) is covered if the patient 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.
  2. A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.
  3. Side rails (E0305, E0310) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.
  4. Safety enclosures (E0316) are covered when they are required by the patient's condition and they are an integral part of, or an accessory to, a covered hospital bed.
  5. If a patient's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a patient owned hospital bed.

Items that are not covered

Including but not limited to the following:

  1. Beds-oscillating and lounge beds, bed baths and lifters, bedboards, tables and other bed accessories
  2. Positioning rolls or pillows
  3. Environmental products -e.g. hypoallergenic bedding, linens
  4. Heat and massage foam cushion pads
  5. Massage devices
  6. Orthopedic mattresses
  7. Waterbeds
  8. Other convenience reasons, such as because member is unable to walk upstairs to bedroom.
  9. Ordinary beds
  10. Enclosed beds such as but not limited to Vail, Posey or Pedicraft; pediatric hospital grade fully enclosed crib (E0300). These items are considered custodial care equipment but could be considered an option for a covered bed if medical necessity criteria is met.
  11. Orthopedic beds, including the mattresses
  12. Overbed table (E0274, E0315)

Definitions

Fixed Height Hospital Bed (E0250, E0251, E0290, and E0291) is one with manual head and leg elevation adjustments but no height adjustment.

Variable Height Hospital Bed (E0255, E0256, E0292, E0293) is one with manual height adjustment and with manual head and leg elevation adjustments.

Semi-electric hospital bed (E0260, E0261, E0294, and E0295) is one with manual height adjustment electric head and leg elevation adjustments.

Total electric hospital bed (E0265, E0266, E0296, E0297) is one with electric height adjustment and with electric head and leg elevation adjustments.

Heavy Duty Extra Wide Hospital Bed (E0301, E0303) is capable of supporting a patient who weighs more than 350 pounds, but no more than 600 pounds.

Extra Heavy-Duty Hospital Bed (E0302, E0304) is capable of supporting a patient who weighs more than 600 pounds.

Ordinary Bed is one which is typically sold as furniture. It may consist of a frame, box spring and mattress. It is a fixed height and may or may not have head or leg elevation adjustments.

Safety Enclosure (E0316) is used to prevent a patient from leaving the bed.

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.

Codes

Description

E0250

Hospital bed, fixed height, with any type side rails, with mattress

E0251

Hospital bed, fixed height, with any type side rails, without mattress

E0255

Hospital bed, variable height, hi-lo, with any type side rails, with mattress

E0256

Hospital bed, variable height, hi-lo, with any type side rails, without mattress

E0260

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress

E0261

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress

   

E0265

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress

E0266

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

E0271

Mattress, innerspring

E0272

Mattress, foam rubber

E0274

Over-bed table

E0280

Bed cradle, any type

E0290

Hospital bed, fixed height, without side rails, with mattress

E0291

Hospital bed, fixed height, without side rails, without mattress

E0292

Hospital bed, variable height, hi-lo, without side rails, with mattress

E0293

Hospital bed, variable height, hi-lo, without side rails, without mattress

E0294

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

E0295

Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress

E0296

Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress

E0297

Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress

E0301

Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress

E0302

Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress

E0303

Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress

E0304

Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress

E0305

Bedside rails, half-length

E0310

Bedside rails, full-length

E0315

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

E0316

Safety enclosure frame/canopy for use with hospital bed, any type

E0329

Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress

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

E0912

Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, freestanding, complete with grab bar

E0940

Trapeze bar, freestanding, complete with grab bar

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.

Bibliography

  1. NCD for Hospital Beds (280.7) - http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=227&ncdver=1&bc=BAABAAAAAAAA&
  2. LCD for Hospital Beds And Accessories (L27216) – 2/4/11 - http://apps.ngsmedicare.com/applications/Content.aspx?DOCID=20489&CatID=3&RegID=51&ContentID=34411
  3. Article for HOSPITAL BEDs And Accessories - Policy Article - Effective October 2009 (A47240 - http://apps.ngsmedicare.com/applications/content.aspx?docid=20488&CatID=3&RegID=51

Go to

Policy activity

  • 01/01/1994 - Date of origin
  • 04/04/2017 - Effective date
Review date
  • 03/2017
Revision date
  • 03/18/2016

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