Pressure Reducing Support Surfaces
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Defines medical necessity, coverage limitations, and coding for pressure-reducing support surfaces (mattress overlays, specialty mattresses, and specialty beds) as durable medical equipment for Aetna members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Support Surfaces
inv-01: Group 1 Support Surfaces (medically necessary when...)
Group 1 support surfaces are medically necessary when:
Group1-pathways
- a: Completely immobile — member cannot make changes in body position without assistance.
b_or_c
- b: Limited mobility — member cannot independently make changes in body position significant enough to alleviate pressure.
- c: Any stage pressure ulcer on trunk or pelvis.
d_to_g
- d: Impaired nutritional status.
- e: Fecal or urinary incontinence.
- f: Altered sensory perception.
- g: Compromised circulatory status.
inv-02: Group 2 Support Surfaces (medical necessity pathways)
Group 2 support surfaces (alternating pressure, low air loss) are medically necessary when ANY of the following pathways is met:
Group2-pathways
- path1: Member has multiple stage II pressure ulcers on the trunk or pelvis (a) AND has been on a comprehensive ulcer treatment program for at least the past month which included an appropriate Group 1 support surface (b) AND the member's ulcers have worsened or remained the same over the past month (c).
- path2: Member has large or multiple stage III or stage IV pressure ulcer(s) on the trunk or pelvis (d).
path3
- e: Recent myocutaneous flap or skin graft for a pressure ulcer on trunk or pelvis (surgery within past 60 days).
- f: Member was on a Group 2 or 3 support surface immediately prior to recent discharge from hospital or nursing facility (discharge within past 30 days).
inv-03: Group 3 (Air-fluidized bed) criteria
Support surfaces are considered medically necessary when ALL of the features specified for the relevant group are met and when the medical necessity criteria for that group are satisfied.
inv-05: Group-based medical necessity criteria
Additional coverage rules, exclusions, and investigational statements:
Bottoming out must be assessed per policy-specified test positions (supine flat, supine head elevated ≤30°, and side-lying).
These contraindications can preclude coverage.
Check benefit plan descriptions for additional exclusions.
Coverage for an air-fluidized bed is limited to the equipment itself. Architectural adjustments (for example, electrical upgrades or structural modifications to support the weight of an air-fluidized system) are generally excluded from coverage. In addition, services provided by informal caregivers related to air-fluidized bed setup or ongoing operation are excluded. Providers and suppliers should confirm specific plan benefit details in the member's benefit plan.
Aetna does not cover ordinary air mattresses that are not designed as alternating-air or low-air-loss therapeutic devices because they do not meet Aetna's contractual definition of durable medical equipment. Examples of non-covered consumer-style products include the Air Flow Mat air-filled vibrating mattress and the Air-O-Pad air mattress.
A support surface that fails to meet the specific dimensional and functional characteristics required by its assigned group will usually be considered not medically necessary. Products that are nonconforming to the policy's group definitions (including device construction, inflated cell or overall heights, pump/blower functionality, or other required features) may be denied as not meeting the policy criteria.
Clinical Policy Bulletins are intended to assist with administration of plan benefits and provide a partial, general description of benefits. They do not constitute a contract or guarantee of coverage; specific benefit determinations depend on the member's benefit plan and on documentation that supports medical necessity. Policies may be updated and are subject to change.
When the policy's medical necessity criteria for Group 1, 2 or 3 support surfaces are not met, the device (including air-fluidized beds) is considered experimental and investigational and therefore not covered. In addition, air-fluidized beds have no proven value for persons with listed contraindications (for example, inadequate electrical or structural support, caregiver inability, co-existing pulmonary disease, or need for wet soaks/moist dressings not protected by an occlusive covering), which can also preclude coverage.
Support surfaces that permit bottoming out — defined by the policy as the ability to readily palpate the bony prominence between the undersurface of the overlay or mattress and the bony prominence when tested in specified positions — are considered not medically necessary and may be denied.
Products that do not meet the policy-specified characteristics for their stated group (for example, required heights, functional pump/blower features, or construction criteria) will usually be considered not medically necessary and therefore not covered.
Coding and Code Lists
| A4640 | Replacement pad for use with medically necessary alternating pressure pad owned by patient |
| E0181 | Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty |
| E0182 | Pump for alternating pressure pad, for replacement only |
| E0183 | Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty |
| E0184 | Dry pressure mattress |
| E0185 | Gel or gel-like pressure pad for mattress, standard mattress length and width |
| E0186 | Air pressure mattress |
| E0187 | Water pressure mattress |
| E0188 | Synthetic sheepskin pad |
| E0189 | Lambswool sheepskin pad, any size |
| L89.101-L89.159 | Pressure ulcer of back |
| L89.200-L89.229 | Pressure ulcer of hip |
| L89.301-L89.329 | Pressure ulcer of buttock |
| L89.40-L89.45 | Pressure ulcer of contiguous site of back, buttock and hip |
| L89.810-L89.899 | Pressure ulcer of other site |
| R40.0 | Somnolence |
| R40.1 | Stupor |
| R40.3 | Persistent vegetative state |
| R40.4 | Transient alteration of awareness |
| Z74.01 | Bed confinement status |
| I96 | Gangrene, not elsewhere classified |
| L89.101-L89.159 | Pressure ulcer of back |
| L89.200-L89.229 | Pressure ulcer of hip |
| L89.301-L89.329 | Pressure ulcer of buttock |
| L89.40-L89.45 | Pressure ulcer of contiguous site of back, buttock and hip |
| R64 | Cachexia |
| Z74.01 | Bed confinement status |
| E0194 | Air fluidized bed |
| I96 | Gangrene, not elsewhere classified |
| R64 | Cachexia |
| L89.101-L89.159 | Pressure ulcer of back |
| L89.200-L89.229 | Pressure ulcer of hip |
| L89.301-L89.329 | Pressure ulcer of buttock |
| L89.40-L89.45 | Pressure ulcer of contiguous site of back, buttock and hip |
| Z74.01 | Bed confinement status |
| R64 | Cachexia |
| J40-J47.9 | Chronic lower respiratory diseases |
| J86.0-J94.9 | Other pleural/pulmonary diseases (examples listed) |
| J96.00-J99 | Other diseases of respiratory system |
| L89.500-L89.629 | Pressure ulcer of ankle or heel (listed as not covered for indications in CPB) |
| M86.071 | Osteomyelitis and related codes (see policy appendix for full list) |
| M86.079 | Osteomyelitis (see policy appendix) |
| M86.171-M86.179 | Osteomyelitis codes |
| M86.271-M86.279 | Osteomyelitis codes |
| M86.371-M86.379 | Osteomyelitis codes |
| M86.471-M86.479 | Osteomyelitis codes |
| M86.571-M86.579 | Osteomyelitis codes |
| M86.671-M86.679 | Osteomyelitis codes |
| M86.8x7 | Osteomyelitis codes |
| M86.9 | Osteomyelitis, unspecified |
Provider Actions and Operational Rules
Air-fluidized bed contraindications
An air-fluidized bed is contraindicated and considered to have no proven value when any of the following conditions exist: inadequate electrical system for increased energy consumption; inadequate structural support (systems may weigh ~1,600 pounds or more); caregiver unwilling or unable to provide required care; co-existing pulmonary disease that impairs effective coughing or worsens secretions; need for wet soaks or moist wound dressings that cannot be made impervious; or other known contraindications to air-fluidized bed use.
- Electrical system insufficient for anticipated increased energy consumption
- Structural support inadequate to support air-fluidized bed weight
- Caregiver unwilling/unable to provide required care
- Co-existing pulmonary disease (ineffective cough, thickened secretions)
- Requires wet soaks or moist dressings not protected by occlusive covering
- Any other documented contraindication to air-fluidized bed use
Policy update and coverage risk notice
Coverage for an air-fluidized bed is limited to the equipment itself. Architectural, structural, or electrical improvements needed to accommodate the bed and services of informal caregivers are generally excluded. Providers should verify member benefits and limitations against the member's plan; changes to coverage criteria may occur and could affect medical necessity determinations.
- Architectural adjustments (electrical/structural) generally excluded from coverage
- Services of informal caregivers excluded — check benefit plan descriptions
- Verify plan-specific limits and recent policy updates prior to ordering
Air-fluidized bed assessment and recertification
An air-fluidized bed must be ordered in writing by the attending physician based on a comprehensive assessment and evaluation after a conservative treatment program has been tried without success. The evaluation generally must be performed within one week prior to initiation of therapy. The physician must direct the home treatment regimen and reevaluate and recertify medical necessity on a monthly basis.
- Physician-ordered comprehensive assessment within 1 week prior to initiation
- Conservative treatment trial (generally ≥1 month) documented as tried and failed
- Monthly physician reevaluation and recertification required for continued coverage
Comprehensive ulcer treatment documentation requirement
The comprehensive ulcer treatment program should be documented in the medical record and generally include moisture/incontinence management, turning and positioning, appropriate wound care for stage II–IV ulcers, patient and caregiver education, nutritional assessment/intervention, and regular assessment by a licensed practitioner (usually at least weekly for stage III/IV ulcers). If on a group 2 surface, a physician-or home-care-nurse established care plan must be present.
- Moisture/incontinence management
- Turning and positioning
- Appropriate wound care (stage II–IV)
- Education for patient and caregiver
- Nutritional assessment and intervention
- Regular assessment by nurse/physician/licensed practitioner (usually ≥ weekly for stage III/IV)
- If on group 2 surface, physician/home care nurse-established care plan required
Care plan documentation required
Patients using pressure-reducing support surfaces must have a documented care plan established by the physician and home care nurse in the medical record. The care plan should include the comprehensive ulcer treatment elements, and evidence that other aspects of the plan are modified when healing does not continue or documentation that continued use of the device is medically necessary for wound management.
- Care plan documented by physician and home care nurse in medical records
- Includes comprehensive ulcer treatment elements
- Documentation when continued device use is required or other care plan modifications are being made
Group-based device categorization
Support surfaces are categorized by group based on the clinically predominant component (usually the topmost layer). Examples: Group 2 includes powered pressure-reducing mattresses, advanced non-powered overlays (with defined performance features); Group 3 includes air-fluidized beds. Providers must select devices using the group definitions and ensure the product meets the required device characteristics for that group.
- Group 2: powered pressure-reducing mattresses, semi/total electric hospital beds with powered mattresses, advanced non-powered overlays that meet listed features
- Group 3: air-fluidized beds (e.g., Clinitron)
- Multi-component products are categorized by clinically predominant component
Escalation pathway and provider responsibilities
If device selection, clinical documentation, or prior-authorization requirements are unclear or a denial is received, follow the payer's escalation and appeal pathways promptly. Document all clinical rationale, responses to additional information requests, and any modifications to the care plan. Verify device characteristics against policy criteria before submission to avoid delays.
- Follow payer escalation/appeal processes if prior auth denied or additional information requested
- Document clinical rationale and care-plan modifications when appealing
- Confirm device characteristics meet policy criteria before ordering/submission
Medical Necessity Mapping and Evidence
inv-42: DME medical necessity mapping to equipment groups (Group 1/2/3 summary)
DME medical necessity mapping to equipment groups — select equipment consistent with the group-based clinical criteria and device feature requirements:
inv-43: Device feature compliance (device must meet all feature requirements for its assigned group)
Device feature compliance — a device must meet all feature requirements for its assigned group to be considered medically necessary:
inv-44: Evidence informing necessity (systematic reviews and studies cited)
Evidence informing medical necessity determinations — systematic reviews, randomized trials, guidelines and policy references cited in the policy inform coverage decisions (evidence does not create alternate eligibility pathways):
See references cited in policy (chunks 36–37).
Rental, Purchase, and Specific Device Notes
| Equipment | Rental vs Purchase Rule |
|---|---|
| Air‑fluidized beds (Group 3) | Not specified in this excerpt; policy states coverage is limited to the equipment itself and architectural adjustments and informal caregiver services are generally excluded (see policy limitations). Specific rental vs purchase instructions are not provided in the cited segments. |
| Specialty mattresses/overlays (Group 1 and Group 2 devices) | Not specified in this excerpt; HCPCS codes for these devices are listed, but the document does not provide rental versus purchase rules in the provided segments. |
| Equipment | Rental vs Purchase Rule |
|---|---|
| Dolphin Bed / fluid immersion systems | Not specified in this excerpt; background describes device features and clinical/cost alternative role to air‑fluidized therapy but does not specify rental versus purchase rules. |
| Policy Metadata | Rental vs Purchase Rule (excerpt status) |
|---|---|
| Policy number: 0430; Effective date: 06/12/2001; Last review: 06/19/2023; Next review: 04/25/2024 | Not specified in the provided excerpt — the document notes that rental vs purchase rules are not included in these segments. |
| HCPCS codes and device lists present (see coding section for covered codes) | No rental/purchase guidance present in cited excerpts; equipment coverage focus and HCPCS listing are provided but rental vs purchase rules are absent. |
Replacement Parts and Accessories
Required Documentation and Records
Submit written physician order and supporting documentation for specialty beds and Group 2/3 devices
Include a written physician order based on a comprehensive assessment and provide supporting documentation of prior conservative treatments, care plan, and device feature compliance when requesting specialty beds (air-fluidized) or for demonstrating medical necessity for Group 2/3 devices.
- Written order must be based on assessment and evaluation (generally within 1 week prior to initiation for air-fluidized beds).
- Provide evidence of prior conservative treatment (typically ≥1 month) and the documented care plan.
Document required care plan elements in the medical record
Document the care plan elements in the medical record: moisture/incontinence management, turning and positioning, wound care for stage II–IV ulcers, patient/caregiver education on prevention/management, nutritional assessment/intervention, and regular licensed assessments.
- If member is on a Group 2 surface, the care plan should be established by the physician or home care nurse and include these elements.
- Regular assessments (usually at least weekly for stage III/IV ulcers) should be documented.
Provide supporting medical records and justification per plan requirements
Provide the plan with supporting medical records and justification to substantiate medical necessity and adherence to policy requirements when requesting coverage or prior authorization; Clinical Policy Bulletins are guidance and do not replace required documentation.
- Include clinical notes, wound measurements, documentation of conservative treatments, care plan, and device specifications.
- Demonstrate that all alternative equipment have been considered and ruled out when required.
Not Covered Items and Exclusions
Ordinary air mattresses that are not alternating-air or low-air-loss therapeutic devices (i.e., consumer-style air mattresses) and architectural modifications necessary to install/operate an air-fluidized bed are not covered under the policy. Refer to the policy exclusions for examples and check the member's benefit plan for additional details.
Examples of air mattresses specifically identified as not covered include the Air Flow Mat air-filled vibrating mattress and the Air-O-Pad air mattress; these ordinary air mattresses do not meet the DME definition used by the plan.
Support surfaces that do not meet the policy's stated characteristics for any group (i.e., nonconforming products) are usually considered not medically necessary and are not covered.
As noted elsewhere in the policy, consumer-style air mattresses that are not therapeutic alternating-air or low-air-loss systems are excluded from coverage. See the policy exclusions for the listed examples of ordinary air mattresses that are not covered.
Background and Policy Scope
Pressure-relieving support surfaces are designed to conform to body contours and distribute pressure over a larger area to prevent or promote healing of pressure ulcers. Selection among alternating-air, low-air-loss, and air-fluidized systems is informed by guidelines and evidence, but comparative efficacy among advanced surfaces is limited; higher-cost devices are therefore reserved for more severe or refractory ulcers.
Defined Terms
Evidence Informing Policy and References
inv-44: Evidence informing necessity (systematic reviews cited such as Cochrane, Tricco, Colin, McInnes)
Key systematic reviews and evidence sources cited in the policy include:
References: Tricco (chunk 37) and related systematic reviews listed in the references section (chunks 36–37).
See policy references (chunks 36–37).
Policy Dates and Revision History
Policy last reviewed on 06/19/2023; review entry recorded in policy history.
Policy effective date established as 06/12/2001.
Next policy review scheduled for 04/25/2024 (as noted in policy metadata).
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