Clinical UM Guideline
|Subject:||Hospital Beds and Accessories|
|Guideline #:||CG-DME-15||Current Effective Date:||10/14/2014|
|Status:||Reviewed||Last Review Date:||08/14/2014|
This document addresses 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.
Note: Please see the following related document for additional information:
A fixed height hospital bed is considered medically necessary if one or more of the following criteria are met:
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:
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 (i.e., 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 medical necessity 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.
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 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:
A frame/canopy for use with a hospital bed and limb restraints is considered not medically necessary since these items are not primarily medical in nature.
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.
|E0250-E0251||Hospital bed, fixed height, with any type side rails|
|E0255-E0256||Hospital bed, variable height, hi-lo, with any type side rails|
|E0260-E0261||Hospital bed, semi-electric (head and foot adjustment), with any type side rails|
|E0265-E0266||Hospital bed, total electric (head, foot, and height adjustments), with any type side rails|
|E0290-E0291||Hospital bed, fixed height, without side rails|
|E0292-E0293||Hospital bed, variable height, hi-lo, without side rails|
|E0294-E0295||Hospital bed, semi-electric (head and foot adjustment), without side rails|
|E0296-E0297||Hospital bed, total electric, (head, foot and height adjustments), without side rails|
|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|
|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|
|E0280||Bed cradle, any type|
|E0305||Bed side rails, half-length|
|E0310||Bed side 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|
|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-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
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:
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.
This Clinical UM Guideline is based on Centers for Medicare and Medicaid Services (CMS) criteria.
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Hospital Beds and Accessories
|Reviewed||08/14/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Description and Websites updated.|
|Reviewed||08/08/2013||MPTAC review. Websites and References updated.|
|01/01/2013||Updated Coding section with 01/01/2013 HCPCS descriptor change.|
|Reviewed||08/09/2012||MPTAC review. Websites and References updated.|
|Reviewed||08/18/2011||MPTAC review. Websites and References updated.|
|Reviewed||08/19/2010||MPTAC review. Websites and References updated.|
Removed not medically necessary statement addressing the Vail enclosure bed. Removed place of service. References updated.
|Reviewed||08/28/2008||MPTAC review. References updated.|
|01/01/2008||Updated coding section with 01/01/2008 HCPCS changes.|
|Revised||08/23/2007||MPTAC review. Addition of medically necessary statement for enclosure beds. References and coding updated.|
|Revised||12/07/2006||MPTAC review. Enclosure beds moved from medically necessary to not medically necessary. Added medically necessary language addressing heavy duty trapeze equipment. References and coding updated.|
|New||12/01/2005||MPTAC initial guideline development.|
|DME.211||Hospital Beds and Accessories|
|DME.004||Hospital Beds & Other Bed Accessories|
|Benefit Detail||Hospital Bed|
|DME Coverage Criteria Guideline, Section D||Hospital Beds and Accessories|
|WellPoint Health Networks, Inc.||No Document|