Prior authorization and coverage criteria

Coverage for safety enclosure beds is subject to InterQual CP clinical coverage criteria for Durable Medical Equipment: Support Surfaces and Hospital Beds, Cribs, and Accessories; safety enclosure frames/canopies should be billed with HCPCS code E0316 and are covered only when the InterQual criteria (including diagnosis related to cognitive impairment or severe behavioral disorder and other listed requirements) are met.

• Reference InterQual CP: Durable Medical Equipment: Support Surfaces; Hospital Beds, Cribs, and Accessories for detailed medical necessity criteria.
• Use HCPCS E0316 for safety enclosure frame/canopy.

Step therapy / conservative measures required

Less intensive alternatives must be tried and found unsuccessful or contraindicated before an enclosed bed is approved; examples include mattress on floor, medical helmet, removal of hazards, side rails, and weighted blankets.

• Try and document alternatives such as mattress placed on the floor, medical helmet, removal of safety hazards, side rails, and weighted blankets.

Medical records required for review

Medical records may be required to determine whether the member meets the clinical criteria for coverage; documentation should support the clinical rationale and demonstrate that required conservative measures were tried or contraindicated.

• Provide clinical notes that document diagnosis, safety risks, medication optimization status, and trials of less intensive measures.

Denial risk: use as restraint

Requests for enclosed bed systems will be denied when the device is used to restrain a beneficiary for behavioral control, caregiver need, or convenience; ensure clinical justification does not reflect restraint as the purpose.

• Do not request coverage when the stated purpose is restraint for behavioral conditions, caregiver convenience, or general convenience.

Chart documentation to support medical necessity

Include chart documentation that supports medical necessity per the InterQual criteria and demonstrates that less intensive alternatives were attempted or are contraindicated; medical records should document diagnosis, safety risk details, medication optimization, and the outcomes of conservative measures.

• Document the diagnosis related to cognitive impairment or severe behavioral disorder.
• Document that medications have been optimized or are not appropriate.
• Document specific safety risks (e.g., high fall risk, uncontrolled movements, violent/self-destructive behaviors).
• Document trials and results of less intensive alternatives or reasons they are contraindicated.