CurrentKaiser PermanentePolicy N/A

Pressure reducing support surfaces (DME) — Clinical Review Criteria

Clinical review criteria for pressure reducing support surfaces (Group 1, 2, 3) used to prevent or heal pressure ulcers; intended for Kaiser Permanente providers and internal reviewers. Applies to Medicare and non‑Medicare members with differences noted by plan type.

Policy Summary

PayerKaiser Permanente

PolicyPressure reducing support surfaces (DME) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeClarified linkage to LCDs

Effective DateN/A

Next Review DateN/A

Key ActionWhen requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Medicare coverage criteria are used for commercial criteria and now linked directly to the Local Coverage Determinations (LCDs).

3Pressure reducing support surface groups (Group 1, 2, 3)

>=6Clinical notes timeframe to submit with request (last 6 months)

Coverage Criteria for Pressure Reducing Support Surfaces

Medicare members

Covered when criteria in the applicable CMS/NCD/LCD policy statements are met:

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ALL of the following

Coverage determination follows CMS Coverage Manuals, National Coverage Determinations (NCD) and applicable Local Coverage Determinations (LCDs) for pressure reducing support surfaces (see referenced LCDs).
Refer to LCDL33830 (Group 1), LCDL33642 (Group 2), LCDL33692 (Group 3) and applicable CMS/NCD policies as cited in the policy document.

ALL of the following

When requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.
Clinical documentation timeframe: Last 6 months required.

Non‑Medicare members

Coverage differs by Group:

Group-specific coverage

Group 1
- Group 1: Medical necessity review not required.
Group 2
- Group 2: Considered medically necessary when criteria in the applicable policy statements are met.
  Linked to LCDL33642 and related policy article A52490.
Group 3
- Group 3: Considered medically necessary when criteria in the applicable policy statements are met.
  Linked to LCDL33692 and related policy article A52468.

ALL of the following

When requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.
Clinical documentation timeframe: Last 6 months required.

Relevant HCPCS Code Groups

Group 1 HCPCSHCPCS

A4640	Replacement pad for use with medically necessary alternating pressure pad owned by patient
E0181
E0182	for replacement only pad
E0183	Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty
E0184	Pressure mattress dry
E0185
E0186	Air pressure mattress
E0187	Water pressure mattress
E0188	Synthetic sheepskin pad
E0189	Lambswool sheepskin pad, any size

1–10 of 14

1/2

Group 2 HCPCSHCPCS

E0193	Powered air flotation bed (low air loss therapy)
E0277	Powered pressure-reducing air mattress
E0371	Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372	Powered air overlay for mattress, standard mattress length and width
E0373	Nonpowered advanced pressure reducing mattress

Group 3 HCPCSHCPCS

E0194

Air fluidized bed

What Providers Must Do

Documentation Required

Submit recent clinical notes

When requesting pressure reducing support surfaces, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Last 6 months of clinical notes required to support medical necessity
Use notes to document how member meets applicable LCD/NCD criteria where required

Prior Authorization

Verify authorization requirements

Use the Pre-authorization Code Check to verify whether a specific HCPCS code requires prior authorization for the member's plan; coverage for both Medicare and non‑Medicare members depends on meeting the applicable LCD/NCD criteria.

Medicare coverage follows CMS Coverage Manuals, NCDs and the listed LCDs (see LCDL33830, LCDL33642, LCDL33692)
Non‑Medicare Group 2 and 3 coverage is linked to the applicable LCDs and their policy articles

Clinical and Policy Background

Pressure relieving support surfaces are designed to prevent or promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. These devices typically conform to the body so that pressure is redistributed over a larger surface area rather than concentrated on a single location, thereby reducing risk of skin breakdown.

This policy aligns with Medicare Durable Medical Equipment (DME) guidelines. Coverage determinations follow applicable CMS guidance including National Coverage Determinations and the referenced Local Coverage Determinations (LCDL33830 for Group 1; LCDL33642 for Group 2; LCDL33692 for Group 3) and their associated policy articles.

For non‑Medicare members, Group 1 basic support surfaces do not require medical necessity review; Groups 2 and 3 (advanced and highest-level support surfaces) are considered medically necessary only when the criteria in the applicable LCDs and policy articles are met. When requesting these services, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Defined Terms

Definitions

Pressure Reducing Support Surfaces Group 1Basic support surfaces and accessories; medical necessity review not required for non‑Medicare members per this document.

Pressure Reducing Support Surfaces Group 2Advanced pressure reducing support surfaces (e.g., powered air flotation, advanced overlays/mattresses) that require meeting LCD criteria for coverage.

Pressure Reducing Support Surfaces Group 3Highest level support surfaces (e.g., air fluidized beds) that require meeting LCD criteria for coverage.

Policy Summary

PayerKaiser Permanente

PolicyPressure reducing support surfaces (DME) — Clinical Review Criteria

Policy CodePolicy N/A

Change TypeClarified linkage to LCDs

Effective DateN/A

Next Review DateN/A

Key ActionWhen requesting this service, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

SourceLink

On This Page

OpenPayer

Pressure reducing support surfaces (DME) — Clinical Review Criteria

Coverage Criteria for Pressure Reducing Support Surfaces

Relevant HCPCS Code Groups

What Providers Must Do

Clinical and Policy Background

Defined Terms

Policy Changes

Clinical Documentation & Timeframes

Pressure reducing support surfaces (DME) — Clinical Review Criteria

Coverage Criteria for Pressure Reducing Support Surfaces

Relevant HCPCS Code Groups

What Providers Must Do

Clinical and Policy Background

Defined Terms

Referenced LCDs / Related Policies

Policy Changes

Clinical Documentation & Timeframes