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Beds and Mattresses (for Ohio Only)
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Defines coverage guidance for hospital beds, bed accessories, and pressure-reducing support surfaces for members in Ohio and references Ohio Administrative Code and InterQual criteria for medical necessity.
Medical Records Documentation Used for Reviews section was expanded to specify required documentation and that documentation does not guarantee coverage.
Applicable Codes list updated to add 'Safety Sleeper ® ' and remove 'Posey' as examples of safety enclosure beds.
Policy explicitly limits application to the state of Ohio and references Ohio Administrative Code for coverage criteria and limitations.
Coverage Criteria
Coverage contingent on state code and InterQual criteria
Covered when ALL of the following are met per referenced sources:
Refer to the cited OAC Rule 5160-10-18 for clinical coverage requirements for hospital beds, bed accessories, and pressure-reducing support surfaces; refer to InterQual CP for safety enclosure clinical criteria.
Coverage limitations and exclusions for hospital beds, bed accessories, and pressure-reducing support surfaces are governed by Ohio law. Refer to Ohio Administrative Code Rule 5160-10-01 (DMEPOS: General Provisions) for general coverage and payment policies and Ohio Administrative Code Rule 5160-10-02 for repair-related limitations and exclusions. Specific items or services excluded from coverage are those identified in the cited OAC rules.
Benefit coverage is determined by federal, state, or contractual requirements and applicable law; medical record documentation may be required to assess clinical eligibility but does not guarantee coverage. The patient's record must contain documentation that fully supports medical necessity, including, at minimum, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation must be maintained in the record and made available upon request to support review.
Coding and HCPCS
| E0193 | Powered air flotation bed (low air loss therapy). |
| E0194 | Air fluidized bed. |
| 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. |
Provider Actions and Prior Authorization
Prior authorization per Ohio OAC and InterQual
Prior authorization decisions for beds and accessories will follow Ohio Administrative Code Rule 5160-10-18; for safety enclosures, reviewers will use InterQual CP: Durable Medical Equipment, Hospital Beds, Cribs and Accessories. Safety enclosures should be coded as E0316 per the policy coding guidance.
- Follow OAC Rule 5160-10-18 for hospital beds, bed accessories, and pressure-reducing support surfaces.
- Use InterQual CP for clinical criteria applicable to safety enclosures (referenced in policy).
- Safety enclosure HCPCS example: E0316.
Step therapy not specified — evaluate per OAC/InterQual
This policy does not define a step-therapy sequence; medical necessity and any required prior steps are evaluated according to Ohio Administrative Code Rule 5160-10-18 and InterQual criteria as applicable.
Required medical record documentation for review
The patient's medical record must contain documentation that fully supports the medical necessity for the requested beds or accessories.
- Relevant medical history
- Physical examination findings
- Results of pertinent diagnostic tests or procedures
- Instructions for use when applicable
- Documentation must be legible, maintained in the medical record, and made available upon request
Denial risk if medical necessity not documented
Requests may be denied when the member’s medical record does not contain documentation that fully supports medical necessity; documentation alone does not guarantee coverage.
- Denials may occur if required elements (history, exam, test results) are missing or insufficient
- Documentation must be producible upon request to support the determination
Medical Necessity Standards
State and InterQual-based medical necessity
Medical necessity must meet the clinical criteria in the Ohio Administrative Code or InterQual as applicable.
Policy delegates detailed clinical requirements and thresholds to the referenced OAC rule and InterQual criteria.
Rental and Purchase Rules
| Equipment | Rental vs Purchase Rule (reference) |
|---|---|
| General DME (beds and accessories) | |
| Refer to Ohio Administrative Code Rule 5160-10-01 for general coverage and payment policies governing rental versus purchase decisions for durable medical equipment, including hospital beds and accessories. |
Replacements and Accessories
Documentation Requirements
Documentation required for medical necessity review
For review of medical necessity, include the patient’s relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures; ensure records are legible and available upon request.
- Relevant medical history and clinical course
- Physical exam that supports need for the requested equipment
- Pertinent diagnostic test results or procedure reports
- Instructions for use when applicable
- Records must be legible, retained in the patient record, and provided if requested by the reviewer
Not Covered / Exclusions
Items or services that are explicitly excluded by the Ohio Administrative Code are not covered under this policy. For determinations of specific not-covered items and repair exclusions, consult Ohio Administrative Code Rule 5160-10-01 and Rule 5160-10-02, which list the applicable exclusions and repair-related limitations.
Background
Hospital beds and pressure-reducing support surfaces are durable medical equipment used to support patients with mobility limitations, risk of pressure injury, or other clinical needs. Equipment types covered by this policy include standard and adjustable hospital beds (fixed height, hi-lo/variable height, semi-electric, and total electric), pediatric hospital-grade cribs, heavy-duty and extra heavy-duty beds by weight capacity, and pressure-reducing mattresses such as powered air flotation and air-fluidized systems. Safety enclosure frames or canopies are recognized as bed accessories for select patients to reduce entrapment risk. Reviewers should refer to Ohio Administrative Code criteria and InterQual clinical guidance for specific indications, thresholds, and place-of-service considerations.
Definitions
Revision History
Expanded 'Medical Records Documentation Used for Reviews' to specify required documentation elements (medical history, physical exam, pertinent diagnostic results), legibility, retention in the record, and availability upon request; clarified that documentation may be required but does not guarantee coverage.
Updated Applicable Codes examples for safety enclosure beds by adding 'Safety Sleeper ®' and removing 'Posey'.
Archived previous policy version CS181OH.E and updated supporting FDA and References sections to reflect current information.
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