CurrentHighmark DelawarePolicy N/A
Support Surfaces (Alternating Pressure Mattresses and Air Fluidized Beds)
Certificate of Medical Necessity form and coverage checklist for Group II alternating pressure mattress (E0277) and Group III air fluidized bed (E0194), documenting clinical criteria, assessment, and documentation required to support coverage for treatment and prevention of decubitus (pressure) ulcers.
Policy Summary
PayerHighmark Delaware
PolicySupport Surfaces (Alternating Pressure Mattresses and Air Fluidized Beds)
Policy CodePolicy N/A
Change TypeNo material change
Effective Date
Next Review Date
Key ActionComplete and submit the CMN with physician signature and required documentation (ulcer stage/size or risk status, conservative treatment history, caregiver availability, device-specific home assessment for E0194 or failure of Group I for E0277) and estimated length of need.
POLICY UPDATE CHANGES
No material clinical or coverage changes.
2Device Groups Covered
60Recent flap/graft exclusion (days)
99Code for permanent need
Coverage Summary
Certificate of Medical Necessity (CMN) form and coverage checklist for Group II alternating pressure mattress (E0277) and Group III air fluidized bed (E0194). Coverage is covered with criteria and requires a completed CMN with physician signature (stamps not acceptable) and documentation of the clinical items on the form.