These services may or may not be covered by all HealthPartners Care 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.
Clinics should direct members to contact a contracted DME vendor to order the item.
Prior authorization is not required for rental or purchase of manual beds (Codes E0250, E0251, E0255, E0256, E0290, E0291, E0292, E0293) or for members enrolled in a hospice program.
For all other bed types for non-hospice 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 link to 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 – Minnesota Health Care Programs” for coverage.
Generally covered subject to the indications listed below and following limits from your member contract:
- Standard manual hospital beds – Including but not limited to the following codes: E0250, E0251, E0255, E0256, E0290, E0291, E0292, E0293
- Documentation in the provider’s file must establish medical necessity as described in this section.
- A medical condition that requires positioning of the body in ways not feasible in an ordinary bed, where pillows or wedges do not meet the recipient’s needs;
- A medical condition that requires special attachments, such as traction equipment, that cannot be fixed and used on an ordinary bed;
- A medical condition that requires the head of the bed to be elevated more than 30 degrees, where pillows or wedges do not meet the recipient’s needs.
- For variable height manual hospital beds:
- A bed height different than a fixed height hospital bed to permit transfers in or out of the bed
- A change of the bed height to enable caregiver(s) to assist with recipient care
- For Semi-electric, total head, and foot adjustment beds - Including but not limited to the following codes: E0260, E0261, E0294, or E0295, AND Total-electric beds – Including but not limited to the following codes: E0265, E0266, E0296, or E0297
- Semi-electric hospital beds:
- Frequent changes in body position to alleviate pain or address a medical condition
- Immediate changes in body position to alleviate pain or address a medical condition
- Total electric hospital beds
- Require a change of bed height at least once a day to allow a caregiver to assist with recipient care
- The caregiver is unable to change the bed height manually, but is able to assist with all necessary cares in bed
- Bariatric xxtra-heavy duty, extra-wide hospital beds - Including but not limited to the following codes: E0301, E0302, E0303, E0304
- Must meet above requirements and the member’s weight is within the capacity limits of the requested bed.
- Pediatric hospital beds – codes: E0328 and E0329
- Covered for members who meet criteria for the type of hospital bed requested (manual, semi-electric, total electric) and who have medical needs best met by a pediatric sized bed. The bed must be reasonably expected to meet the member’s needs for at least five years.
- Replacement mattress/Bed rails - Including but not limited to the following codes:E0271 and E0272 for mattress and E0305, E0310 for bed rails
- Covered when used with a hospital bed.
- Bed enclosure (Vail, Posey, Pedicraft) - Including but not limited to the following code: E0316 and Hospital grade enclosed crib - Including but not limited to the following code: E0300
- This type of bed is considered medically necessary and the least costly alternative in only the most extreme conditions, due in part to the restrictive nature of the bed and the confinement it entails.. Based on advice from medical consultants, MHCP considers an enclosed bed medically necessary when the member is cognitively impaired and mobile if his/her unrestricted mobility has resulted in documented injuries sustained as a result of wandering unsupervised. Even then it must be shown that other, less costly methods have been attempted and have failed to effectively treat the problem. Generally, such confinement is not medically necessary nor the least costly way of managing seizures or behaviors such as head banging, rocking, etc. Issues of sensory deprivation and the potential for overuse must also be addressed in this process.
- Coverage will be considered for members who have documented evidence of unsafe mobility (climbing out of bed and moving around the home, not just standing at the side of the bed), including mobility that will put the member at risk for serious injury, not just a possibility of injury.
- The following criteria must be met:
- Diagnosis of one of the following:
- Brain injury
- moderate to severe cerebral palsy
- Seizure disorder with daily seizure activity
- Developmental disability
- Severe behavioral disorder
- Documentation of a specific risk from unrestricted mobility including:
- Tonic-clonic type seizures
- Uncontrolled perpetual movement related to diagnosis
- Self-injurious behavior
- Less costly alternatives must have been tried or considered and rejected including any of the following (not all-inclusive):
- Padding around regular or hospital bed
- Placing the mattress on the floor
- Medications to prevent seizures and to correct behaviors
- Behavior modification strategies
- Helmets for head banging
- Removing safety hazards from the member’s bedroom and using a child protection device on the door knob
- Baby monitors to listen in on member’s activity
- MHCP believes that there is no clear-cut medical justification for the enclosed bed systems. The real need is to proactively address with intervention the underlying medical and/or behavioral issues that give rise to the risk of harm.
- Hospital beds are expected to serve the recipient for at least 5 years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization.
Indications that are not covered
Including but not limited to the following:
- Beds which are typically sold as furniture, including adjustable beds that are not manufactured as durable medical equipment
- Orthopedic matresses
- Oscillating and lounge beds
- Bed tables and other bed accessories
- Bedding or linens, including hypoallergenic bedding
- Heat and massage pads
- Enclosed beds for recipients with awake caregivers 24 hours per day
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 - full line
- Items must be received from a contracted vendor who carries a full line of DME equipment.
- Full line vendors provide a wide range of equipment and supplies, such as hospital beds, aids for ambulating and toileting, phototherapy lights, wheelchairs, custom seating devices, monitors, pumps, oxygen and etc.
This policy follows the Minnesota Health Care Plans (MHCP) Provider Manual of the MN Department of Human Services.