Safety Items (DME and related safety devices)
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Defines Aetna's coverage stance for safety items (durable medical equipment and related devices) including which items are excluded under standard plans and which may be covered under non-standard plans when medically necessary.
No material clinical or coverage changes in this revision.
Coverage Criteria
inv-01: Medically necessary safety items (non-standard plans)
Covered under non-standard plans when ALL of the following apply
Supported by policy text
Policy lists examples of items that may be considered medically necessary under non-standard plans
Policy DME definition exclusion
inv-02: Excluded safety items (standard plans)
Not covered under standard plans
Policy states standard HMO and non-HMO plan exclusions
Telephone alert systems (also called emergency medical alert button systems) are not covered because they do not meet Aetna's contractual definition of durable medical equipment. These systems are normally of use in the absence of illness or injury and therefore fall outside the DME definition. The policy notes that telephone alert systems typically consist of a worn distress-signal activator (necklace or bracelet) that relays preprogrammed messages to predetermined telephone contacts; examples include AlertOne and Lifeline. Check the member's benefit plan description for plan-specific details.
Safety and athletic prescription lenses and frames are excluded under the standard vision exclusion. These items are listed among safety-related devices that standard Aetna benefit plans typically exclude; coverage depends on the member's specific benefit plan.
Items that are normally useful in the absence of illness or injury do not meet Aetna's definition of covered DME and are therefore excluded. Examples explicitly cited in the policy include car safety seats, fire extinguishers, first aid kits, knee and elbow pads, safety goggles, and smoke and carbon monoxide detectors.
Under most standard Aetna benefit plans, safety interventions and devices are excluded from coverage regardless of whether they are integral to the management of the member's condition. The policy states that standard HMO-based and standard non-HMO plans typically exclude charges for items furnished to provide a safe surrounding or to make the surrounding free from exposure that can worsen the disease or injury.
NOT COVERED — commonly excluded safety items include: telephone alert systems (emergency medical alert button systems), car safety seats, fire extinguishers, first aid kits, knee and elbow pads, safety goggles, and smoke and carbon monoxide detectors. These items are normally useful in the absence of illness or injury and are therefore excluded under Aetna's DME coverage criteria; plan details should be verified in the member's benefit description.
Coding
| A8000 | Helmet, protective, soft, prefabricated, includes all components and accessories |
| A8001 | Helmet, protective, hard, prefabricated, includes all components and accessories |
| A8002 | Helmet, protective, soft, custom fabricated, includes all components and accessories |
| A8003 | Helmet, protective, hard, custom fabricated, includes all components and accessories |
| A8004 | Soft interace for helmet, replacement only |
| E0241 | Bathtub wall rail, each |
| E0242 | Bathtub rail, floor base |
| E0243 | Toilet rail, each |
| E0300 | Pediatric crib, hospital grade, fully enclosed, with or without top enclosure |
| E0305 | Bedside rails, half-length |
| No codes listed |
| 61304-61619 | Craniectomy or craniotomy and other cranial surgeries |
Medical Necessity
inv-16: DME medical necessity criteria (non-standard plans)
Medical necessity for DME safety items under non-standard plans requires all of the following:
Policy examples include frequent, violent or uncontrolled seizures, balance disorders, head banging behaviors, and post-cranial surgery
Policy lists item-specific examples of medically necessary DME under non-standard plans
Provider Actions
Prior Authorization May Be Required
Prior authorization may be required for certain durable medical equipment (DME) safety items when the member's benefit plan is non-standard. Providers should verify benefits and obtain prior authorization when plan language or coverage rules indicate authorization is needed before delivery or billing.
- Affected HCPCS/CPT/HCPCS-represented items: safety beds and bed rails, hospital bedside rails/enclosure frames, specialized protective helmets, telephone alert systems (typically not DME), grab bars when covered under non-standard plans
- Verify member's plan type (standard vs non-standard) and benefit language before ordering
- Obtain prior authorization when required by the member's plan
Denial Risk for Standard Plans
Claims for safety items are likely to be denied when submitted under standard Aetna benefit plans because these plans commonly exclude items furnished primarily to provide a safe surrounding or to prevent exposure that can worsen a condition. Providers should anticipate denials if the member's plan contains standard exclusions for safety items.
- Commonly denied items under standard plans: car seats, fire extinguishers, first aid kits, knee/elbow pads, safety goggles, smoke and carbon monoxide detectors, telephone alert systems
- Expect denial for items furnished mainly to provide a surrounding free from exposure that can worsen the person's disease or injury
Documentation to Support Medical Necessity
When submitting requests or claims for safety items under non-standard plans that allow coverage, include documentation that supports medical necessity. Documentation should demonstrate the member's condition places them at increased risk of injury or makes them especially susceptible to harm from injury.
- Document clinical diagnosis and objective evidence of increased risk (e.g., seizure disorder with documented falls/injuries, balance disorder assessments)
- Provide treatment history and rationale why the safety item is medically necessary (e.g., helmet after cranial surgery, bed rails for recurrent falls from bed)
- Include durable medical equipment definition justification if item is normally useful absent illness/injury (to address DME criteria)
If the member's plan is standard, do not assume coverage; safety items are frequently excluded even when they might be integral to management. Providers should review benefit plan descriptions and communicate potential noncoverage to members before providing items.
- Check the member's contract for explicit exclusions before ordering
- Obtain informed financial consent from the member if the plan likely denies coverage
- Consider alternative clinically appropriate interventions that may be covered
Definitions
Background
Background: Safety items are devices or interventions intended to prevent injury or provide protection for members who are at increased risk because of medical or neurocognitive conditions. The policy explains that many safety items are ordinarily useful in the absence of illness or injury and may therefore not meet the contractual definition of DME. For non-standard plans that do not exclude safety items, certain devices (for example, continuously worn prefabricated or custom protective helmets, bedside rails, enclosed pediatric cribs, safety enclosure frames, belts/harnesses/vests, and restraints) may be considered medically necessary when the member's condition places them at increased risk of injury or makes them especially susceptible to harm.
Rental & Purchase Rules
| Item | Rental vs Purchase | Notes / Policy guidance |
|---|---|---|
| Hospital bed safety enclosure frames | Not specified (refer to benefit plan descriptions and related CPBs) | Policy does not specify whether hospital bed safety enclosure frames should be rented or purchased; refer to the member's benefit plan descriptions and related clinical policy bulletins (e.g., hospital bed policies) for rental vs purchase rules. |
| Other durable medical equipment listed in this policy (e.g., bedside rails, enclosed pediatric cribs, belts/harnesses/vests, restraints) | Not specified (refer to benefit plan descriptions and related CPBs) | Rental vs purchase rules for other DME safety items are not defined in this policy; check the applicable benefit plan and related Aetna CPBs for guidance. |
Replacement
Documentation
Document condition, clinical rationale, and plan coverage
Maintain medical records that support the member's condition, provide the clinical rationale for the requested safety device, and document that the member's benefit plan permits coverage of safety items.
- Records should demonstrate increased risk of injury or susceptibility to harm from injury related to the member's condition.
- When applicable, include operative or other evidence of cranial surgery to justify helmet coverage as a prosthetic of the skull.
- Confirm and document that the member's benefit plan does not exclude safety items.
Not Covered
NOT COVERED — The policy enumerates specific items that are not covered as DME because they are normally useful outside of an illness or injury context or are contractually excluded under standard plans. These include telephone alert systems (emergency medical alert button systems), car safety seats, fire extinguishers, first aid kits, knee and elbow pads, safety goggles, smoke and carbon monoxide detectors, and other listed safety items such as bedside monitors, grab bars, helmets used for nonmedical reasons, service dogs, and vehicular restraint systems. Always verify coverage against the member's benefit plan description.
Revision History
Policy last reviewed on 2023-11-14; status listed as current with next review scheduled
Policy effective date established as 2002-06-18
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