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.

SourceLink

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.

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The CMN must document key elements including: physician supervision and monthly reevaluation; evidence of failure of conservative therapy (e.g., frequent repositioning, optimal wound care, nutrition); assessment of pressure ulcer status or high-risk status with ulcer stage and size when present; availability of a trained full-time caregiver; and device-specific prerequisites such as home structural/electrical assessment for E0194 or prior trial and failure of a Group I support surface before E0277 is requested.

Provider Actions & Documentation Requirements

Prior Authorization

Complete Certificate of Medical Necessity (CMN)

Submit a completed Certificate of Medical Necessity (CMN) with the physician’s ORIGINAL signature and date. The CMN must include responses to all Y/N/D items and documentation of ulcer stage and size or high-risk status, a history of conservative treatment, caregiver availability, device-specific prerequisite assessment (home assessment for E0194 or failure of Group I for E0277), and the estimated length of need.

E0277
E0194
Required documentation elements: ulcer stage and size or risk status; conservative treatment history; caregiver availability; device-specific home assessment for E0194 OR failure of Group I for E0277; estimated length of need

Documentation Required

Physician supervision and monthly reevaluation

Document that the physician will supervise use of the device for treatment and prevention of decubiti and will perform and record monthly progress reevaluations in the medical record and on the CMN (Y/N/D question on the form).

Documentation Required

Conservative treatment failure documentation

Document prior conservative measures tried (for example, frequent repositioning, optimal wound care, nutrition) and the results. After failure of conservative treatment, include a comprehensive assessment recorded on the CMN and in the medical record.

Billing Rule

Home assessment for Air Fluidized Bed

For E0194 requests, document that the patient’s home has been assessed for adequate structural support and electrical system capacity to safely accommodate the air fluidized bed (the form notes the bed weight of approximately 1600 pounds).

E0194

Background

This CMN form is used to support coverage decisions for support surfaces (alternating pressure mattresses and air fluidized beds) for the treatment and prevention of pressure (decubitus) ulcers. The form documents prior conservative therapy failure, assessment of ulcers or risk, caregiver availability, device-specific prerequisites, and provider attestations required to determine medical necessity.

Definition: CMN (Certificate of Medical Necessity) — the form required to document clinical criteria and provider attestations for support surfaces. Definition: Group I/II/III — support surface grouping where Group I = pressure-reducing foam or gel, Group II = alternating pressure mattress (E0277), and Group III = air fluidized bed (E0194).