Hospital Beds and Accessories
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Coverage and medical necessity criteria for hospital beds, mattresses, bed accessories, and related equipment for Aetna members. Applies to DME requests and suppliers seeking coverage determinations.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
inv-01: Initial medical necessity for hospital bed
Aetna considers hospital beds medically necessary DME for members who meet any of the following:
Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed.
inv-02: Type-specific criteria (semi-electric, total electric, variable height)
Specifications for bed types and additional criteria:
Semi-electric = manual height adjustment with electric head and leg elevation adjustments.
Total electric = electric height adjustment and electric head and leg elevation adjustments.
Variable height bed = manual height adjustment with manual head and leg adjustments (unless specified electric).
inv-03: Electric adjustment criteria
Electric powered adjustment criteria:
Upon medical review, exceptions to criterion 2 can be made for members with spinal cord injury and brain damage.
inv-04: Mattress and scale criteria
Built-in scale and mattress criteria:
inv-05: Bed accessories
Accessories coverage:
inv-06: Experimental / investigational
Experimental / Not covered conditions:
Aetna excludes items that are primarily furniture or comfort/ convenience devices from coverage as durable medical equipment. Ordinary (non‑hospital) beds—frames sold as furniture with a box spring and mattress, fixed height, and no head/leg elevation adjustments—do not meet the definition of covered DME because they are not primarily used in the treatment of disease or injury. Power or manual lounge beds (examples: Adjust‑A‑Sleep, Select Comfort/Sleep Number, Craftmatic, Electropedic, Sealy Posturpedic, Simmons Beautyrest) and specialty consumer mattresses (memory foam/visco‑elastic, waterbeds) are also not covered. Institutional‑type beds intended for inpatient settings (e.g., oscillating, springbase, circulating, cage, and Stryker‑frame beds) and many accessories that are safety or convenience items (e.g., over‑bed tables, bed boards, bed trays, bed elevation blocks, bed lifters, bed baths, bedside rail pads, call switches) are similarly excluded from coverage for home use.
Requests for items that are primarily safety devices—such as enclosure beds and frame/canopy systems, limb restraints, and other safety‑only accessories—are generally excluded because they are considered measures to provide a safe surrounding rather than treatment of disease or injury. Providers should check members’ benefit plan descriptions for any additional plan‑specific exclusions or limitations before billing.
The policy identifies Vail enclosed bed systems (Vail 500, 1000, 2000) as a safety and regulatory concern. In 2005 the FDA and Department of Justice seized finished Vail enclosed bed systems because of entrapment and suffocation risks; the manufacturer subsequently announced it would permanently cease manufacture, sale, and distribution of these systems and will no longer supply accessories, replacement parts, or retrofit kits. Suppliers and providers should not attempt to source parts or rely on manufacturer support for Vail enclosed beds, and use of these systems is discouraged due to documented public health risk.
Beds that deliver kinetic therapy (continuous lateral rotation/turning beds) or provide vibration/percussion therapy are considered experimental or investigational for outpatient or long‑term use. The policy notes that evidence for prevention or treatment of pressure ulcers and pulmonary complications is limited and inconsistent; therefore turning/rotational beds and vibration/percussion devices are not established as effective for the indicated outpatient/long‑term uses and are treated as non‑covered in those contexts. Clinical use in acute, monitored inpatient settings may be informed by the literature, but routine home or long‑term provision is not supported by the policy.
Medical Necessity Rules and Evidence
inv-36: DME medical necessity nodes
Medical necessity rules for DME hospital beds and related features:
Exceptions to frequent/immediate need may be made on medical review for spinal cord injury and brain damage.
inv-37: Kinetic/rotational bed evidence
Evidence summary relevant to clinical decision-making for kinetic/rotational beds:
HCPCS and Diagnosis Codes
| E0250 | Hospital bed, fixed height, with any type side rails, with mattress. |
| E0251 | Hospital bed, fixed height, with any type side rails, without mattress. |
| E0255 | Hospital bed, variable height, hi-lo, with any type side rails, with mattress. |
| E0256 | Hospital bed, variable height, hi-lo, with any type side rails, without mattress. |
| E0260 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress. |
| E0261 | Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress. |
| E0265 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress. |
| E0266 | Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress. |
| E0271 | Mattress, inner spring [covered for member owned hospital bed, if condition requires replacement]. |
| E0272 | Mattress, foam rubber [covered for member owned hospital bed, if condition requires replacement]. |
| E0270 | Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress. |
| E0273 | Bed board. |
| E0274 | Over-bed table. |
| E0305 | Bedside rails, half-length (safety item). |
| E0310 | Bedside rails, full-length (safety item). |
| E0315 | Bed accessory: board, table, or support device, any type. |
| E0700 | Safety equipment (e.g., belt, harness or vest). |
| E0710 | Restraints, any type (body, chest, wrist or ankle). |
| E0184 | Dry pressure mattress. |
| E0186 | Air pressure mattress. |
| E0194 | Air-fluidized bed. |
| E0196 | Gel pressure mattress. |
| E0197 | Air pressure pad for mattress, standard mattress length and width. |
| E0277 | Powered pressure-reducing air mattress. |
| E0370 | Air pressure elevator for heel. |
| E0371 | Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width. |
| E0372 | Powered air overlay for mattress, standard mattress length and width. |
| E0373 | Nonpowered advanced pressure reducing mattress. |
| Z91.81 | History of falling [At risk for falls or climbing out of bed] |
| No codes listed |
Provider Responsibilities and Billing Guidance
HCPCS Codes Requiring Selection Criteria
HCPCS codes listed in this policy are covered only when the selection/medical necessity criteria in the policy are met.
- Covered HCPCS codes require the member to meet the hospital bed medical necessity criteria in the policy before coverage (see policy criteria for fixed, variable height, semi-electric, total electric, heavy-duty and extra heavy-duty beds).
- HCPCS codes listed as not covered in the policy (e.g., E0270, E0273, E0274, E0305, E0310, E0315, E0700, E0710) are excluded for the indications described; do not bill these expecting coverage.
Safety/Regulatory Action for Vail Enclosed Beds
On March 22, 2005 the FDA and Department of Justice seized finished Vail enclosed bed systems (Vail 500, 1000, 2000) due to risk of entrapment and suffocation; Vail ceased manufacture and will not provide parts or retrofit kits. Revised instructions/warnings were distributed in June 2005 with use restrictions (e.g., not for persons under 45 inches tall or under 46 lbs, and not for those who burrow, are violent/combative/suicidal, have multiple lines, or have pica).
- Do not provide, bill, or supply replacement parts or retrofit kits for Vail enclosed bed systems — product is no longer supported by manufacturer.
- If an existing Vail system remains in use, follow the revised manufacturer warnings and restrictions; consider safety and clinical appropriateness.
- Report any safety concerns per FDA/reporting requirements.
No Specific Denial Triggers Specified
The policy excerpts do not specify any provider actions that will automatically cause a denial beyond the listed non-covered items and exclusions; denials are triggered when services/items do not meet the medical necessity criteria or when excluded HCPCS codes are billed for non-covered indications.
- No additional explicit denial triggers are listed in these excerpts beyond: billing excluded HCPCS codes, providing non-covered lounge/ordinary beds, and billing safety/enclosure items generally excluded by the plan.
- Clinical review and plan benefit terms determine final coverage/denial decisions.
Clinical Documentation Required
Document and retain clinical evidence that the member meets the medical necessity criteria for the specific hospital bed type requested.
- Clinical indications supporting selection (e.g., need to position body in ways not feasible in ordinary bed; need for special attachments; need to elevate head >30° most of the time for CHF, chronic pulmonary disease, or aspiration risk).
- For variable height beds: documentation of severe arthritis, lower extremity injuries, severe cardiac conditions, spinal cord injury/amputations/stroke with transfer needs, or other severely debilitating conditions requiring height variation.
- For electric adjustments: evidence the member can operate controls and requires frequent or immediate changes in body position; note exceptions may be made for spinal cord injury or brain damage on medical review.
- Weight documentation when requesting heavy-duty ( >350 lb and ≤600 lb) or extra heavy-duty (>600 lb) beds.
- If requesting a built-in scale, document non-ambulatory status and need for periodic weight measurements.
- If a mattress is billed separately for member-owned bed, document clinical need for replacement (e.g., innerspring or foam replacement).
No Specific Documentation Requirements Specified
The policy excerpts do not provide a comprehensive list of documentation procedures or forms; links and clinical criteria are provided instead. Providers should follow plan-specific prior authorization instructions when present.
- No specific documentation templates or submission checklists are included in these excerpts — supply clinical notes, measurements, and functional assessments that demonstrate criteria are met.
- Follow payer prior authorization portals and guidance (if prior auth is required by plan) for required forms and supporting records.
Step Therapy (Informational)
Informational: rotational/kinetic/turning beds have mixed evidence. Some studies suggest reduced incidence of nosocomial pneumonia but no consistent effect on mortality or length of stay; technical parameters and patient selection remain uncertain.
- Step-therapy note: rotational/kinetic beds (continuous lateral rotation therapy) are not described as required initial therapy prior to other beds; their clinical benefit is limited and should be considered on a case-by-case basis.
- Evidence shows possible reduction in pneumonia incidence but inconsistent impact on other outcomes; use clinical judgment and consult policy sections on turning/rotational beds.
No Step Therapy Requirements Described
The policy excerpts do not impose formal step therapy requirements (i.e., no mandatory trial of a less complex bed before authorization of a higher-spec bed is specified).
- Although clinicians should consider less complex beds first (e.g., ordinary or fixed height beds when appropriate), the policy does not mandate a step-up pathway in the provided excerpts.
- Coverage is determined by documented medical necessity for the specific bed type requested.
Rental, Purchase, and Allowance Policies
| Item | Rule |
|---|---|
| Mattress provided with a rented hospital bed | |
| A separate charge for replacement mattresses should not be allowed where the hospital bed with mattress is rented. |
| Item | Rule |
|---|---|
| Replacement innerspring or foam mattress for member-owned hospital bed | |
| If a member's condition requires a replacement innerspring mattress or foam rubber mattress, it will be considered medically necessary for a member-owned hospital bed. |
| Item | Billing/Coding Rule |
|---|---|
| Hospital bed provided with mattress and/or bedside rails | |
| When mattress or bedside rails are provided at the same time as a hospital bed, they are included in the allowance for the corresponding bed and should be billed using the single combined code that represents the bed with mattress/rails. |
Required Documentation and Notes
Document clinical rationale tied to specific policy criteria
Clinical rationale must tie to the policy criteria and evidence: document inability to use an ordinary bed or the need for special attachments, and explicitly document when sustained head-of-bed elevation >30 degrees is required for cardiopulmonary or aspiration indications.
- Include clinical findings and prior attempts (e.g., pillows/wedges) to demonstrate necessity.
- Relate requests for higher-spec beds (electric/variable height) to the specific criteria in the policy.
Bill single combined code for bed plus included accessories
When a bed is furnished together with a mattress or bedside rails, bill the single combined code rather than separate codes for the accessories.
- The appendix specifies which mattress and rail items are included in the bed allowance — follow that guidance when coding.
Do not source Vail parts from manufacturer — not available
Vail Products will no longer provide accessories, replacement parts, or retrofit kits for Vail enclosed bed systems; suppliers cannot obtain parts from the manufacturer.
- The FDA/DOJ seizure and company cessation of manufacture mean these products are not supported and should not be sourced.
- Revised manuals/warnings were issued and the product poses entrapment risk.
No additional equipment-specific documentation requirements in excerpts
No equipment-specific documentation requirements are provided in the supplied excerpts; the policy supplies additional information links for glossary and resources that providers may consult.
- Unless plan-specific or regional instructions exist, rely on the policy’s general documentation requirements tied to medical necessity criteria.
Key Definitions
Items and Systems Not Covered
The following items are specifically identified as not covered: ordinary (non‑hospital) beds and furniture‑type beds that are primarily for comfort or sold as household furniture; power or manual lounge beds and named consumer adjustable beds; memory foam/visco‑elastic mattresses and waterbeds; and institutional‑type hospital beds (oscillating, springbase, circulating, cage, Stryker‑frame) which are inappropriate for home use. Most enclosure beds, frame/canopy safety systems (including SleepSafe and similar products), limb restraints, and many bedside accessories used solely for safety or convenience (e.g., bed baths, bed boards, bed elevation blocks, bed lifters, over‑bed tables, bed trays, bedside rail pads, call switches) are also excluded from coverage because they are not considered treatment of disease or injury. Providers should verify plan benefits prior to submission.
Vail enclosed bed systems and related accessories/retrofits are not acceptable for coverage or supply due to regulatory action and the manufacturer’s cessation of production and support. The FDA/DOJ seizure (2005) documented significant entrapment and suffocation risks; Vail Products has stated it will no longer provide accessories, replacement parts, or retrofit kits. Because the manufacturer cannot supply parts or support, these systems and any attempts to source parts from the manufacturer are effectively unavailable and should not be used or billed as covered DME.
Replacement and Maintenance
Background and Context
Hospital beds are durable medical equipment intended to address medical needs that ordinary beds cannot meet. Typical clinical indications include provision of sustained positional therapy to relieve pain or prevent contractures, accommodation of special attachments (for example, traction) that cannot be affixed to an ordinary bed, and the ability to maintain head‑of‑bed elevation greater than 30 degrees most of the time for conditions such as congestive heart failure, chronic pulmonary disease, or aspiration risk. The policy emphasizes that pillows or wedges should be considered first for modest elevation needs and that a requirement for a particular bed height alone rarely justifies a hospital bed; clinical documentation must support inability to meet needs with an ordinary bed or demonstrate the criteria above.
Policy Revision History
Policy originally became effective.
FDA and DOJ initiated seizures of Vail enclosed bed systems due to safety risks, later leading to cessation of manufacture and distribution of Vail products.
Document last reviewed; policy status listed as current with next review scheduled.
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