Pressure Reducing Support Surfaces - Group 1
Group 1 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this Category include non-powered pressure reducing mattresses, pressure pads and mattress overlays (foam, air water, or gel). A Group 1 mattress overlay or mattress is covered if one of the following three criteria is met:
1. The beneficiary is completely immobile- i.e., beneficiary cannot make changes in body position without assistance, or
2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of the conditions A-D below.
3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of the conditions A-D below.
A. Impaired nutritional state
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status
Coverage and Payment Policy
This service does not require prior authorization.
Click here for an approved PDF version of the Pressure Reducing Support Surfaces Group 1 policy.
Pressure Reducing Support Surfaces - Group 2
Group 2 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses.
A Group 2 support surface is covered if the beneficiary meets at least one of the following three criteria (1, 2, or 3):
1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
a. Use of an appropriate Group 1 support surface, and
b. Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
c. Appropriate turning and positioning, and
d. Appropriate wound care, and
e. Appropriate management of moisture/incontinence, and
f. Nutritional assessment and intervention consistent with the overall plan of care
2. The beneficiary has large or multiple stage III or IV pressure ulcers(s) on the trunk or pelvis
3. The beneficiary has a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a Group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.
If the beneficiary is on a group 2 support surface, there should be a care plan established by the treating physician or home care nurse which includes the above elements.
Coverage and Payment Policy
This service requires prior authorization. The continued use of a group 2 support surface is covered until the ulcer is healed and must be documented by the treating physician every 3 months.
Certificate of Medical Necessity for Support Surfaces is required.
Click here for an approved PDF version of the Pressure Reducing Support Surfaces Group 2 policy.
Pressure Reducing Support Surfaces - Group 3
Group 3 support surfaces are complete bed systems, known as air fluidized beds, which use the circulation of filtered air through silicone beads. A Group 3 support surface is covered only if all of the following criteria are met:
1. The beneficiary has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer.
2. The beneficiary is bedridden or chair bound as a result of severely limited mobility.
3. In the absence of an air-fluidized bed, the beneficiary would require institutionalization.
4. The air fluidized bed is ordered in writing by the beneficiary's attending physician based upon a comprehensive assessment and evaluation of the beneficiary after completion of a course of conservative treatment designed to optimize conditions that promote wound healing. The evaluation must be performed within one month to initiation of therapy with the air-fluidized bed.
5. The course of conservative treatment must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment was rendered. Conservative treatment must include:
a. Frequent repositioning of the beneficiary with particular attention to relief of pressure over bony prominences (usually every two hours); and
b. Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and
c. Necessary treatment to resolve any wound infection; and
d. Optimization of nutrition status to promote wound healing; and
e. Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the wound bed; and
f. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.
In addition conservative treatment should generally include:
g. Education of the beneficiary and caregiver on the prevention and management of pressure ulcers; and
h. Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly, and
i. Appropriate management of moisture/incontinence.
6. A trained adult caregiver is available to assist the beneficiary with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments and management and support of the air-fluidized bed system and its problems such as leakage.
7. A physician directs the home treatment regimen, and reevaluates and re-certifies the need for the air-fluidized bed on a monthly basis.
8. All other alternative equipment has been considered and ruled out.
Coverage and Payment Policy
This service requires prior authorization. The physician must document that the beneficiary has met all of the criteria above. The Certificate of Medical Necessity for Support Surfaces is required. An air-fluidized bed will be denied under any of the following circumstances:
1. The beneficiary has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions);
2. The beneficiary requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material;
3. The caregiver is unwilling or unable to provide the type of care required by the beneficiary on an air-fluidized bed;
4. Structural support is inadequate to support the weight of the air-fluidized bed system (if generally weighs 1600 pounds or more);
5. Electrical system is insufficient for the anticipated increase in energy consumption; or
6. Other known contraindications exist.
The continued coverage of an air-fluidized bed must be documented by the treating physician every month. Continued use of an air-fluidized bed is covered until the ulcer is healed or if healing does not continue, there is documentation to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the bed is reasonable and necessary for wound management.
Click here for an approved PDF version of the Pressure Reducing Support Surfaces Group 3 coverage guidelines.