CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Hospital Beds

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These Guidelines identify the clinical information MassHealth uses to determine medical necessity for hospital beds and specialized pediatric beds used in the home. They apply to providers requesting coverage for MassHealth members and require prior authorization for all hospital beds.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hospital Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for all hospital beds with a prescription, signed letter of medical necessity, and supporting clinical documentation.

SourceLink

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Hospital Beds

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hospital Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for all hospital beds with a prescription, signed letter of medical necessity, and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All bedsPrior authorization

>30°Head elevation threshold

350–600 lbHeavy-duty bed weight

>600 lbExtra-heavy-duty bed weight

4Fixed-height pathways

3Safety enclosure criteria

Hospital Bed Coverage Criteria

Fixed-height hospital bed

Covered when at least one of the following criteria is met:

Fixed-height criteria

The member has a medical condition requiring positioning the body in ways not feasible with an ordinary bed.
The member requires positioning the body in ways not feasible with an ordinary bed to alleviate pain.
The member requires the head of the bed to be elevated more than 30 degrees most of the time because of a medical condition; pillows or wedges must have been tried or considered.>30 degrees most of the time
Elevation of the head or upper body less than 30 degrees does not usually require a hospital bed.
The member requires traction or other equipment that can be attached only to a hospital bed.

Variable-height hospital bed

Covered when all of the following are met:

Variable-height criteria

Fixed-height criterion: At least one fixed-height hospital bed criterion is met.
Height for transfers: The member requires a bed height different from a fixed-height hospital bed to permit transfers to a chair, wheelchair, or standing position.

Semi-electric hospital bed

Covered when all of the following are met:

Semi-electric criteria

Fixed-height criterion: At least one fixed-height hospital bed criterion is met.
Position changes: The member requires frequent changes in body position or may need an immediate change in body position.
Control operation: The member is functionally and cognitively able to operate the controls for adjustment, with or without accessories as needed.

Total-electric hospital bed

Covered when all of the following are met:

Total-electric criteria

Variable-height criteria: All variable-height hospital bed criteria are met.
Semi-electric criteria: All semi-electric hospital bed criteria are met.
Least costly medically appropriate alternative: The total-electric bed is the least costly medically appropriate alternative.

Heavy-duty, extra-wide hospital bed

Covered when both of the following are met:

Heavy-duty, extra-wide criteria

Fixed-height criterion: At least one fixed-height hospital bed criterion is met.
Weight: The member weighs more than 350 pounds but does not exceed 600 pounds.>350 lb and <=600 lb

Extra-heavy-duty, extra-wide hospital bed

Covered when both of the following are met:

Extra-heavy-duty, extra-wide criteria

Fixed-height criterion: At least one fixed-height hospital bed criterion is met.
Weight: The member weighs more than 600 pounds.>600 lb

Pediatric hospital bed or crib without added safety enclosure

Covered when the member meets the criteria for any qualifying hospital bed type:

Qualifying hospital bed type

Fixed-height hospital bed criteria are met.
Variable-height hospital bed criteria are met.
Semi-electric hospital bed criteria are met.
Total-electric hospital bed criteria are met.
Heavy-duty, extra-wide hospital bed criteria are met.
Extra-heavy-duty, extra-wide hospital bed criteria are met.

Pediatric hospital bed or crib with added safety enclosure

Covered when all of the following criteria are met:

Pediatric safety-enclosure criteria

Medical safety risk: The member has a medical condition that puts them at risk for falling out of or seriously injuring themselves while in an ordinary bed or standard hospital bed.
Examples include cognitive or communication impairment or a severe behavioral disorder.
Unsafe mobility history: The member has a history of behavior involving unsafe mobility that puts them at risk for serious injury while in an ordinary bed or standard hospital bed.
An example is climbing out of bed.
Failed or contraindicated alternatives: Less costly alternatives were tried and were unsuccessful or contraindicated.
An example is wearing a protective helmet.

Nonmedical-purpose use: A hospital bed is not medically necessary when it is used primarily and customarily for a nonmedical purpose and is generally useful in the absence of illness, injury, or disability, including use as an ordinary bed.

Less costly alternatives: A hospital bed is not medically necessary when its therapeutic benefits, such as upper-body elevation of more than 30 degrees, can be achieved with less costly alternatives such as pillows or wedges.

Duplicate equipment: Additional hospital bed equipment is not medically necessary when the member already has a hospital bed that meets the member’s medical needs.

Insufficient documentation: Coverage is not available when the submitted documentation is insufficient to establish medical necessity for using a hospital bed to treat the member’s illness or injury.

Codes and Equipment Thresholds

Hospital bed and accessory codesHCPCS

E0250-E0251	Hospital bed, fixed height, with any type side rails
E0255-E0256	Hospital bed, variable height, hi-lo, with any type side rails
E0260-E0261	Hospital bed, semi-electric (head and foot adjustment), with any type side rails
E0265-E0266	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails
E0290-E0291	Hospital bed, fixed height, without side rails
E0292-E0293	Hospital bed, variable height, hi-lo, without side rails
E0294-E0295	Hospital bed, semi-electric (head and foot adjustment), without side rails
E0296-E0297	Hospital bed, total electric (head, foot and height adjustments), without side rails
E0300	Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
E0301-E0304	Hospital bed, heavy duty/extra heavy duty

1–10 of 22

1/3

Head-of-bed elevation

ThresholdMore than 30 degrees most of the time

Clinical basisRequired because of a medical condition

AlternativesPillows or wedges must have been tried or considered

Heavy-duty, extra-wide bed weight

Weight rangeMore than 350 pounds but not more than 600 pounds

Bed typeHeavy-duty, extra-wide hospital bed

Additional requirementAt least one fixed-height hospital bed criterion must be met

Authorization and Coverage Decision Rules

Prior Authorization

Prior Authorization Required for All Hospital Beds

Prior authorization is required for every hospital bed. The DME provider must submit a PA request supported by clinical documentation establishing medical necessity, a written prescription, and a letter of medical necessity signed by the member’s prescribing provider.

If PA is approved, payment remains subject to MassHealth eligibility, other-insurance requirements, and applicable program restrictions.

Documentation Required

Prescription and Medical Necessity Letter

Obtain a written prescription and signed letter of medical necessity from the member’s prescribing provider as part of every hospital-bed PA request. Both documents must satisfy 130 CMR 409.416 and should be completed using the MassHealth Prescription and Medical Necessity Review Form for Hospital Beds.

The prescription and medical-necessity letter must identify and support the requested bed type.

Hospital Bed Background

A hospital bed permits adjustment of the head and legs and can accommodate attachments, such as traction equipment, that cannot be used with an ordinary bed. These features provide a safer environment when the member’s medical needs cannot be met by an ordinary bed. MassHealth evaluates requests individually, using clinical information about the relative risks and benefits of the requested equipment, including possible postoperative recovery needs.

Equipment Definitions

Fixed-height hospital bed

DefinitionA hospital bed that permits manual adjustment of head and leg elevation but not bed height

Head adjustmentManual adjustment

Leg adjustmentManual adjustment

Variable-height hospital bed

DefinitionA hospital bed that permits manual adjustment of bed height, head elevation, and leg elevation

Height adjustmentManual adjustment of bed height

Elevation adjustmentsManual adjustment of head and leg elevation

Equipment-Specific Medical Necessity

Hospital bed equipment-specific criteria

Coverage is determined case by case according to the equipment requested. The member must meet the clinical criteria applicable to that equipment, and the provider must submit documentation supporting those criteria.

Equipment-specific medical necessity

Requested equipment type
- Fixed-height hospital bed
- Variable-height hospital bed
- Semi-electric hospital bed
- Total-electric hospital bed

Medical Necessity Documentation

Documentation Required

Document fixed-height medical necessity

Document one or more applicable fixed-height criteria and the member’s condition and required positioning or elevation. If elevation greater than 30 degrees is required, document attempts to use pillows or wedges and their results; if traction or other equipment is required, identify the equipment, its purpose, and duration of use.

Documentation Required

Document the need for variable height

Document at least one of the four fixed-height hospital bed criteria and describe the medical condition requiring variable height.

Documentation Required

Document semi-electric bed requirements

Document at least one fixed-height criterion, the medical condition requiring frequent and/or immediate changes in body position, and the member’s ability to operate the controls independently. Include adaptive equipment used to operate the bed or, when applicable, documentation supporting clinical appropriateness for a medically complex or neurologically impaired member.

Noncovered Items and Circumstances

Not covered: Ordinary beds used primarily for nonmedical purposes are not covered. Coverage may also be denied when documentation is insufficient to establish medical necessity, when the therapeutic benefit can be achieved with less costly alternatives such as pillows or wedges, or when the member already has a hospital bed that meets the member’s medical needs.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hospital Beds

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for all hospital beds with a prescription, signed letter of medical necessity, and supporting clinical documentation.

SourceLink

On This Page

Extra-heavy-duty, extra-wide bed weight

Weight thresholdMore than 600 pounds

Bed typeExtra-heavy-duty, extra-wide hospital bed

Additional requirementAt least one fixed-height hospital bed criterion must be met

Include all additional clinical documentation needed to establish medical necessity.

Prior Authorization

Submit the PA Request

Providers are strongly encouraged to submit PA requests electronically through the LTSS Provider Portal using the appropriate Prior Authorization Request Type, with all supporting information attached. Alternatively, complete the MassHealth Prior Authorization Request form and submit a non-electronic request using the PA-1 form and supporting documentation by mail to the address on the back of the PA-1 form.

Submit requests in accordance with 130 CMR 409.418.
Direct portal-access questions to the LTSS Provider Service Center at (844) 368-5184.

Documentation Required

Bed-Specific Clinical Documentation

The PA request must include documentation specific to the requested bed type. Document the applicable clinical criteria, the member’s condition and functional needs, relevant failed or unsuitable alternatives, and all required measurements or safety information.

Fixed-height: Describe one or more qualifying needs: positioning not feasible with an ordinary bed, positioning to alleviate pain, elevation greater than 30 degrees with pillow/wedge trials and results, or traction/other equipment attachable only to a hospital bed. Specify the required elevation or, for traction/equipment, the equipment, purpose, and duration.
Variable-height: Document at least one fixed-height criterion and the medical condition(s) requiring variable height.
Semi-electric: Document at least one fixed-height criterion, the frequent or immediate need for position changes, and the member’s ability to operate controls independently, including adaptive equipment; for medically complex or neurologically impaired members, document clinical appropriateness when applicable.
Total-electric: Document that variable-height and semi-electric criteria are met, that the member is fully independent with transfers and needs adjustable height to transfer safely and independently, and that no comparable, available, suitable equipment would meet the need.
Heavy-duty, extra-wide: Document at least one fixed-height criterion and weight greater than 350 pounds but no more than 600 pounds.
Extra-heavy-duty, extra-wide: Document at least one fixed-height criterion and weight greater than 600 pounds.
Pediatric bed/crib without added safety enclosure: Document the criteria for any qualifying hospital bed.
Pediatric bed/crib with added safety enclosure: Document pediatric-bed medical necessity, the condition and clinical need for the enclosure, proven safety risk including unsafe-mobility history and injuries or risks through the request date, and less costly alternatives tried and their results.

Denial Risk

Noncoverage and Denial Conditions

MassHealth does not consider a hospital bed medically necessary when the request does not establish a medically necessary use or when the need can be met through less costly or existing equipment.

The bed is primarily and customarily for a nonmedical purpose and is generally useful without illness, injury, or disability, such as an ordinary bed.
Documentation is insufficient to establish medical necessity for treating the member’s illness or injury.
Therapeutic benefits, including upper-body elevation greater than 30 degrees, can be achieved with less costly alternatives such as pillows or wedges.
The member already has a hospital bed that meets the member’s medical needs, resulting in duplication of equipment.

Denial Risk

Meet the Requested Bed-Type Criteria

Failure to satisfy the criteria for the requested bed type creates a denial risk. The documentation must support the underlying fixed-height need where required and the additional clinical, positioning, transfer, control-operation, weight, safety, or least-cost requirements applicable to the requested model.

Variable-height beds require a qualifying fixed-height need plus a need for a different bed height to permit transfers to a chair, wheelchair, or standing position.
Semi-electric beds require a qualifying fixed-height need, frequent or immediate position changes, and functional and cognitive ability to operate the controls, with accessories as needed.
Total-electric beds require both variable-height and semi-electric criteria and must be the least costly medically appropriate alternative.
Heavy-duty and extra-heavy-duty beds require the applicable fixed-height criterion and the specified weight range.
Pediatric beds or cribs without safety enclosures require criteria for an otherwise qualifying hospital bed.
Pediatric beds or cribs with safety enclosures require all specified medical-necessity, unsafe-mobility/safety-risk, and failed-or-contraindicated less-costly-alternative criteria.

Semi-electric hospital bed

DefinitionA hospital bed with manual height adjustment and electric adjustment of head and leg elevation

Height adjustmentManual adjustment

Elevation adjustmentsElectric adjustment of head and leg elevation

Total-electric hospital bed

DefinitionA hospital bed with electric adjustment of height, head elevation, and leg elevation

Height adjustmentElectric adjustment

Elevation adjustmentsElectric adjustment of head and leg elevation

Pediatric hospital bed

DefinitionA hospital bed that may be manual, semi-electric, or total electric

Possible configurationsManual, semi-electric, or total electric

Safety featureMay include a safety device such as a 360-degree side enclosure

Pediatric crib

DefinitionA hospital-grade bed

Safety featureMay include an added safety enclosure

Equipment categoryPediatric crib

Ordinary bed

DefinitionA furniture item typically sold as a furniture item

Hospital-bed distinctionGenerally does not meet the definition of a hospital bed

DME distinctionDoes not meet the definition of durable medical equipment as defined in 130 CMR 409.402

Heavy-duty, extra-wide hospital bed

Extra-heavy-duty, extra-wide hospital bed

Pediatric hospital bed or crib without an added safety enclosure

Pediatric hospital bed or crib with an added safety enclosure

Applicable clinical criteria: The requested equipment meets the clinical coverage criteria for its equipment type.

Supporting documentation: The provider submits documentation supporting the applicable medical necessity criteria.

Documentation Required

Document total-electric bed requirements

Document that the variable-height and semi-electric criteria are met. Also document that the member is fully independent with transfers, requires adjustable height to transfer safely and independently, and has no other comparable, available, and suitable medical equipment.

Documentation Required

Document heavy-duty bed eligibility

Document at least one fixed-height hospital bed criterion and that the member weighs more than 350 pounds but does not exceed 600 pounds.

Documentation Required

Document extra-heavy-duty bed eligibility

Document at least one fixed-height hospital bed criterion and that the member’s weight exceeds 600 pounds.

Documentation Required

Document criteria for an unenclosed pediatric bed or crib

For a pediatric hospital bed or crib without an added safety enclosure, document the criteria for any applicable hospital bed type under the clinical coverage requirements.

Documentation Required

Document the need for a pediatric safety enclosure

Document the medical necessity for the pediatric hospital bed or crib, the medical condition and clinical need for a safety enclosure, and evidence of proven safety risk. Include the history of unsafe mobility and injuries or risk through the request date, as well as less costly alternatives tried and their results.