BCBSNJ Medical Policy for - (D M E) Policy Number

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Horizon BCBSNJ
Uniform Medical Policy Manual	Section:	D M E
	Policy Number:	021
	Effective Date:	05/12/2020

	Original Policy Date:	02/22/2002
	Last Review Date:	05/12/2020
	Date Published to Web:	07/14/2006

Subject:
Medical Beds

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Medical beds are considered durable medical equipment and are eligible to the extent that the benefit design allows for this type of service and it meets medical appropriateness guidelines. In order to be considered as medically necessary a bed must perform or help in performing some medically necessary function.

Medical necessity describes a service, supply or procedure (collectively "technology") that a physician or health care professional exercising prudent clinical judgment, would provide to a member for the purpose of evaluating, diagnosing or treating an illness, injury, disease or its symptoms and that is:

in accordance with the "generally accepted standards of medical practice";
clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the member's illness, injury or disease;
not primarily for the convenience of the member or the physician or health care professional; and
not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the member's illness, injury or disease.

The basic purpose of a bed in a medical context is to provide a patient with impaired function or other medical problem an ability to ameliorate the medical problem or otherwise aid in performing an essential activity. Such needs include facilitation of feeding, breathing, bathroom activities, use of lifts, and turning of patients who are bed bound. In such bed bound patients medical use of beds may be directed at preventing decubitus ulcers, using traction equipment, specialty mattresses, or restraining an otherwise uncontrollable patient. Use of beds to help ameliorate pain or when the weight of the patient is an issue may be appropriate only when there is a complicating need.

Beds are considered not medically necessary when they are primarily for the patient or patient's family comfort and/or convenience. Furthermore, Horizon BCBSNJ does not provide coverage for larger beds that would accommodate an individual's spouse or serves a function other than medical (ie. furniture, containment). When it is possible to modify a standard bed to satisfy the medical need of the patient (eg. by use of wedges, pillows, step stool, or other device) a medical bed is not considered medically necessary.

Examples of medical conditions in which a medical bed is not generally medically necessary include but are not limited to the treatment of low back pain, fractured ankles or other non-complicated fractures, maternity, pain alone, and weight considerations alone without other complicating factors. In general, specialty beds are not considered medically necessary for the restraint of children with seizures, autism, or other containment problems. The length of time an individual spends in bed does not, by itself create or establish medical necessity.

Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

1. A standard (fixed height) hospital bed (manual head and leg elevation adjustments but no height adjustment) (E0250, E0251, E0290, E0291, and E0328) (which includes a standard mattress, side rails, and electric hospital frame) is generally sufficient to satisfy the medical necessity for a medical bed. It is medically necessary when the following criteria are met:

it is ordered by the treating physician and is accompanied by documentation to support the type of medical bed and/or options/accessories;
the bed must serve a medically necessary function and not be simply for the member's or caregiver's comfort and convenience; and
the bed must ameliorate a medical problem or otherwise aid in performing an essential activity; and
when any of the following conditions exist:

2. Manually adjustable Variable height (high-low) hospital bed (E0255, E0256, E0292, and E0293) with manual head and leg elevation adjustment capability is considered medically necessary when the member meets 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.

3. Semi-electric hospital bed (head and foot adjustment) (E0260, E0261, E0294, E0295, and E0329) is considered medically necessary when the member meets the criteria for a fixed height hospital bed and required frequent changes in body position and/or has an immediate need for a change in body position.

4. Heavy-duty extra wide hospital bed (electric bariatric bed) (E0301, E0303) is considered medically necessary when (a) the member meets the criteria for a fixed height hospital bed, and (b) the member's weight is more than 350 pounds but does not exceed 600 pounds and/or the member's body width exceeds the boundaries of a standard fixed height hospital bed.

5. Extra heavy-duty hospital bed (extra heavy duty electric bariatric bed) (E0302, E0304) is considered medically necessary when the member meets the criteria for a hospital bed and the member's weight exceeds 600 pounds.

6. A standard total electric hospital bed (head, foot, and height adjustments) (E0265, E0266, E0296, E0297) is not considered medically necessary. The electrical height adjustment feature is a convenience feature.

7. An enclosed pediatric crib (E0300) is considered medically necessary when the patient requires position changes an ordinary bed cannot accommodate or condition requires frequent position changes

(

NOTE

U.S. Food and Drug Administration (FDA). In 2005, the FDA issued a Class 1 Device Recall on the Vail 500 Enclosed Bed System and Vail 1000 Enclosed Bed System (Vail Products Inc., Toledo, Ohio) noting “risk of patient entrapment, may result in serious injury or death”. The FDA page titled Hospital Beds (last updated 8/23/18) notes that between January 1, 1985 and January 1, 2013, FDA received 901 incidents of patients caught, trapped, entangled, or strangled in hospital beds. The reports included 531 deaths, 151 nonfatal injuries, and 220 cases where staff needed to intervene to prevent injuries. The FDA and the Hospital Bed Safety Workgroup released ‘Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment’ document on March 10, 2006. This guidance provides recommendations for manufacturers of new hospital beds and for facilities with existing beds (including hospitals, nursing homes, and private residences).

Effective January 2017, the FDA issued a final rule to rename pediatric hospital beds as pediatric medical cribs and established special controls for these devices. The FDA established a separate classification regulation for medical bassinets, previously under the pediatric hospital bed classification regulation, as a class II (special controls) device. This rule continues to allow both devices to be exempt from premarket notification and use of the device in traditional health care settings and permits prescription use of pediatric medical cribs and bassinets outside of traditional health care settings.)

8. Options and accessories are considered medically necessary if they are medically necessary for the member to improve functions or other medical problem or perform an essential activity as outlined above in the description section. For meeting the medically necessary requirements of the member, focus should be on providing the most cost-effective options for making the medically necessary bed available.

If the options and accessories are primarily used for non-medical purposes or for the comfort and or convenience of either the member, member’s family, or caregiver, they are not considered medically necessary and thus, not covered.

9. Horizon BCBSNJ will not pay for over bed tables, pillows, mattress covers, sheets or other bed linen, chucks, blankets, or incontinence pads.

10. In addition to the standard/basic hospital beds along with medically necessary options, certain non-commercially available specialty beds will be made available when the following criteria are met:

Powered Air Flotation Bed (Low Air Loss Therapy)

medically necessary

use of an appropriate group 1 support surface; and
regular assessment by a nurse, physician, or other licensed healthcare practitioner; and
appropriate turning and positioning; and
appropriate wound care; and
appropriate management of moisture/incontinence; and
nutritional assessment and intervention consistent with the overall plan of care.

Air-fluidized beds

medically necessary

the member has a stage III or IV pressure sore and is bed ridden
without the air-fluidized bed, the member would need to be hospitalized
the air-fluidized bed is ordered by the attending physician and is based on a comprehensive assessment and evaluation following failed attempts of one month duration, at conservative treatment to promote wound healing.
(NOTE: Conservative treatment should include frequent positioning, use of specialized support surface for reducing pressure on healing ulcers and preventing new ulcer formation, necessary treatment to resolve wound infection, optimization of nutritional status to promote wound healing, wound debridement by any means, maintenance of clean, moist bed of granulation tissue with moist dressings protected by an occlusive covering during healing.)
there is a trained adult caregiver available to assist the member with activities of daily living, fluid balance, skin care, repositioning, dietary needs, prescribed treatments, and management and support of the bed system and problems such as leakage
a physician-directed home treatment regimen with re-evaluations and recertification exist on a monthly basis
other available alternative equipment has been considered and ruled out.

not considered medically necessary

11. Repairs of medical beds are covered but only for medical beds that Horizon BCBSNJ has approved or would have approved for purchase. This provision is subject to contract limitations.

12. Replacement of a medical bed may be considered eligible for reimbursement in cases of irreparable damage or a change in the member's condition. It is subject to determination of medical necessity. Adequate proof that the unit is beyond repair must be submitted. A statement of medical necessity from the treating physician must be submitted when replacement is due to a change in the member's condition. This provision is subject to contract limitations.

13. Horizon BCBSNJ will not pay for modifications to a home to accommodate a bed.

14. Continued use of rented medical bed and related options/accessories includes all of the following:

timely documentation in the member's medical record showing usage of the item, related options/accessories, and supplies;
supplier records documenting member confirmation of continued use of a rental item.

Medicare Coverage:
There are multiple applicable NCD, LCD and an LCD policy article applicable to this policy. For additional information regarding eligibility and coverage, please refer to the applicable NCD, LCD, and LCD Article below.

National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1).

National Coverage Determination (NCD) for Hospital Beds (280.7).

National Coverage Determination (NCD) for Air-Fluidized Bed (280.8).

Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.

Local Coverage Determination (LCD): Hospital Beds And Accessories (L33820).

Local Coverage Article: Hospital Beds And Accessories - Policy Article (A52508).

Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 2 (L33642).

Local Coverage Article: Pressure Reducing Support Surfaces - Group 2 - Policy Article (A52490)

Local Coverage Determination (LCD): Pressure Reducing Support Surfaces - Group 3 (L33692).

Local Coverage Article: Pressure Reducing Support Surfaces - Group 3- Policy Article (A52468)

Available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.

Medicaid:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE-SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Medical Beds
Beds, Medical
Hospital Beds
Standard Fixed Height Hospital Bed
Variable Height Hospital Bed
Semi-Electric Hospital Bed
Heavy-Duty Extra Wide Hospital Bed
Extra Heavy-Duty Hospital Bed
Total Electric Hospital Bed
Institutional-Type Beds
Air Immersion Beds
Dolphin Fluid Immersion Simulation (FIS) System
Fluid Immersion Simulation (FIS) System
FIS (Fluid Immersion Simulation) System

References:
1. ECRI. Beds, electric. In: Healthcare Product Comparison System, Hospital Edition. Plymouth Meeting, PA: ECRI, 1998.

2. ECRI. Beds, pediatric. In: Healthcare Product Comparison System, Hospital Edition. Plymouth Meeting, PA: ECRI, 1998.

3. ECRI. Special care beds. In: Healthcare Risk Control. Volume 2. Plymouth Meeting, PA: ECRI,1996.

4. Petzall K, Berglund B, Lundberg C. Beds used at a university hospital - a study of functions, problems and requirements. Scand J Caring Sci 1995;9(3):181-186.

5. U.S. Food and Drug Administration - Center for Devices and Radiological Health. Hospital beds and the vulnerable patient. The Hospital Bed Safety Work Group. Updated January 10, 2002. [Available at www.fda.gov/cdrh/beds]

6. Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals. Long Term Care Facilities, and Home Care Settings. Developed by the Hospital Bed Safety Workgroup. April 2003. Available at: https://www.ecri.org/Documents/Patient_Safety_Center/BedSafetyClinicalGuidance.pdf (accessed 11/10/14).

7. Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); January 2012. Available at: http://www.guideline.gov/content.aspx?id=36059&search=turning+bed+AND+bed+sores (accessed 11/10/14)

8. National Coverage Determination (NCD) for Hospital Beds (280.7). Available at https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=227&ncdver=1&bc=AAAAQAAAAAAA&

9. Local Coverage Article: Syandard Documentation Requirements for All Claim Submitted to DME MACs (A55426). Available at https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=55426&ver=76&LCDId=33820&ContrID=140&bc=AAAAAAAAQAAA&

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

HCPCS
E0193

* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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