Coverage Indications, Limitations, and/or Medical Necessity
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For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1-4) are met:
A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the beneficiary meets one 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.
A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.
A heavy duty extra wide hospital bed (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.
An extra heavy-duty hospital bed (E0302, E0304) is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.
A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.
For any of the above hospital beds (plus those coded E1399 - see Policy Article Coding Guidelines), if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary.
If the beneficiary does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary.
ACCESSORIES:
Trapeze equipment (E0910, E0940) is covered if the beneficiary 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 (E0911, E0912) is covered if the beneficiary meets the criteria for regular trapeze equipment and the beneficiary's weight is more than 250 pounds.
A bed cradle (E0280) is covered when it is necessary to prevent contact with the bed coverings.
Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they are required by the beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed.
If a beneficiary's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272) it will be covered for a beneficiary owned hospital bed.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
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Choosing the best mattress is particularly important as you get older as it can help reduce aches and pains, as well as ensure you get a good night’s rest. It’s for this reason that many older people, or those with certain medical conditions, prefer to invest in a specialist mattress that can offer more tailored support.
The downside is that these mattresses can be expensive, so it’s worth knowing that Medicare will cover most of the cost for certain mattresses. Unsure what types of mattresses are covered by Medicare? We’ve done the research for you here...
What types of mattresses are covered by Medicare?
Medicare has certain guidelines that must be met before the cost of your mattress can be covered. For a start, the mattress needs to qualify as Durable Medical Equipment, or DME.
DME is medically necessary equipment prescribed by a doctor to help patients function in their everyday lives. DME items can include crutches, walkers, blood sugar monitors and hospital beds. Certain mattresses are also included, but a doctor is the only person who can give a mattress this designation.
To qualify, the mattress must meet the below conditions:
(Image credit: Drive Medical)
Pressure-reducing mattresses, which are used for certain conditions such as sciatica and arthritis, are usually the only type of mattress covered by Medicare. Some of the top pressure-reducing mattresses that are approved by Medicare are outlined below:
What types of mattresses are not covered by Medicare?
While a number of mattresses will be covered by Medicare, many more mattresses won’t be. If the mattress you’re buying is for non-medical use and if it is not used for specific health care issues like sciatica and arthritis, you won’t be able to get any financial help from Medicare. You won't get it just because you've chosen a mattress for back pain, for instance.
Remember that Medicare will only cover the costs of mattresses that qualify for DME designation and meet the conditions mentioned above.
How much of the mattress purchase will Medicare cover?
You will need to check your specific Medicare coverage to work out how much Medicare will pay and how much you will need to contribute. However, as mattresses are covered under Medicare Part B, in most cases Medicare will cover 80% of the cost of your new mattress and you will need to pay for the remaining 20%. The deductible will also apply, which is $233 in 2022.
Who is eligible for a mattress covered by Medicare?
To be eligible for Medicare help, you will need to get a doctor’s recommendation stating that you have a medical condition that requires you to buy a pressure-reducing mattress to ease discomfort. The note will need to explain what condition you have and how the mattress could improve your health.
Once you’ve received the doctor’s note you will need to submit it to Medicare for consideration. If Medicare approves the request and agrees that you’re eligible, you can go ahead and make your purchase. One further condition is that the mattress must be bought from a Medicare-approved mattress retailer. If it’s not, you won’t receive your funds. You can search for approved suppliers on the Medicare website.
Types of mattresses covered by Medicare: Summary
To summarize, if your mattress meets the following three criteria, Medicare will cover the cost of up to 80% of the mattress price:
You must also have a note from your doctor explaining why you need the mattress, and you must purchase the mattress from a Medicare-approved supplier.
If you do not qualify for financial help from Medicare, it is still possible to find an affordable mattress for your needs. As a first step, make sure you shop around and compare retail options carefully. It is also well worth checking out the latest mattress sales.
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If you want to learn more, please visit our website pediatric hospital bed.