CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Hospital Beds

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Guidelines for providers requesting MassHealth authorization for hospital beds and specialized pediatric beds used in the home.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hospital Beds

Policy CodePolicy N/A

Change TypeRevisionsupersedes December 15, 2010 policy

Effective DateJuly 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for every hospital-bed request 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.

AllPrior authorization

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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.

Guidelines for providers requesting MassHealth authorization for hospital beds and specialized pediatric beds used in the home.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Hospital Beds

Policy CodePolicy N/A

Change TypeRevisionsupersedes December 15, 2010 policy

Effective DateJuly 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for every hospital-bed request 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.

AllPrior authorization

>30°Elevation threshold

350–600 lbHeavy-duty bed range

>600 lbExtra-heavy-duty threshold

4Fixed-height criteria

Hospital Bed Coverage Criteria

Fixed-height hospital bed

A fixed-height hospital bed is medically necessary when at least one of the following criteria is met:

ONE of

Positioning to alleviate pain: The member requires positioning the body in ways not feasible with an ordinary bed in order to alleviate pain.
Elevation greater than 30 degrees: 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
Examples include congestive heart failure, chronic pulmonary disease, or problems with aspiration.
Traction or specialized equipment: The member requires traction or other equipment that can be attached only to a hospital bed.
Medical condition requiring positioning: The member has a medical condition that requires positioning the body in ways not feasible with an ordinary bed.
Elevation of the head or upper body less than 30 degrees does not usually require a hospital bed.

Variable-height hospital bed

A variable-height hospital bed requires the applicable fixed-height criteria and a medical need for variable height.

ALL of the following

At least ONE fixed-height criterion
- Fixed-height criterion: The member meets at least one fixed-height hospital-bed criterion.
Variable-height need: The member has a medical condition requiring variable height.

Semi-electric hospital bed

A semi-electric hospital bed requires all of the following:

ALL of the following

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

Total-electric hospital bed

A total-electric hospital bed requires all of the following:

ALL of the following

Variable-height criteria: The member meets the criteria for a variable-height hospital bed.
Semi-electric criteria: The member meets the criteria for a semi-electric hospital bed.
Least costly appropriate alternative: The total-electric bed is the least costly medically appropriate alternative.

Heavy-duty and extra-heavy-duty extra-wide hospital beds

A heavy-duty or extra-heavy-duty, extra-wide hospital bed requires one fixed-height criterion and the applicable weight threshold:

ONE of the following weight branches

Heavy-duty, extra-wide: The member meets at least one fixed-height hospital-bed criterion and weighs more than 350 pounds but does not exceed 600 pounds.>350 and <=600 pounds
Extra-heavy-duty, extra-wide: The member meets at least one fixed-height hospital-bed criterion and weighs more than 600 pounds.>600 pounds

Pediatric hospital bed or crib

Pediatric beds or cribs without an added safety enclosure require the applicable hospital-bed criteria. With an added safety enclosure, all safety-enclosure criteria must be met.

ONE of the following

Without added safety enclosure: The member meets the criteria for any applicable hospital-bed type.
With added safety enclosure
- Underlying medical and safety risk: The member has a medical condition that puts the member at risk for falling out of or seriously injuring themself 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, such as climbing out of bed, that puts the member at risk for serious injury while in an ordinary bed or standard hospital bed.

A bed used primarily and customarily for a nonmedical purpose and generally useful in the absence of illness, injury, or disability—such as an ordinary bed—is excluded from coverage.

Duplicate equipment is excluded when the member already has a hospital bed that meets the member’s medical needs.

Medical necessity is not established when documentation is insufficient to support use of a hospital bed for treatment of the member’s illness or injury.

A hospital bed is not medically necessary when the therapeutic benefit, such as upper-body elevation greater than 30 degrees, can be achieved with a less costly alternative, such as pillows or wedges.

Coding and Equipment Thresholds

Code List: Beds and AccessoriesHCPCS

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 (includes codes E0301, E0302, E0303, E0304)

1–10 of 22

1/3

Head-of-bed elevation

Clinical thresholdHead of the bed must be elevated more than 30 degrees most of the time because of a medical condition.

Supporting documentationPillows or wedges must have been tried or considered; documentation must describe the attempts and results.

Lower elevationElevation of the head or upper body less than 30 degrees does not usually require a hospital bed.

Heavy-duty, extra-wide bed weight

Weight rangeThe member weighs more than 350 pounds but does not exceed 600 pounds.

Underlying criterionThe member must meet at least one criterion for a fixed-height hospital bed.

Prior Authorization and Provider Actions

Prior Authorization

PA Required for All Hospital Beds

Prior authorization is required for every hospital bed. Submit clinical documentation supporting medical necessity for the requested bed type; approval remains subject to MassHealth eligibility, other insurance, and program restrictions.

PA is required for all hospital beds, including specialized pediatric beds used in the home.
Requests must be submitted in accordance with 130 CMR 409.000 and applicable MassHealth DME requirements.

Documentation Required

Prescription and Letter of Medical Necessity

Every hospital-bed PA request must include a written prescription and letter of medical necessity signed by the member’s prescribing provider, along with any additional clinical documentation supporting medical necessity.

Use the MassHealth Prescription and Medical Necessity Review Form for Hospital Beds.

Background

A hospital bed permits head and leg elevation and can support attachments, such as traction equipment, that cannot be used with an ordinary bed. It provides a safer environment when a member’s positioning, mobility, behavioral, or medical needs cannot be accommodated by an ordinary bed. An ordinary bed is furniture that does not meet the definition of a hospital bed or durable medical equipment.

Equipment Definitions

Fixed-height hospital bed

Equipment typeFixed-height hospital bed.

Manual adjustmentsAllows manual adjustment of head and leg elevation.

Bed heightDoes not allow adjustment of bed height.

Variable-height hospital bed

Equipment typeVariable-height hospital bed.

Height adjustmentAllows manual adjustment of bed height.

Positioning adjustmentsAllows manual adjustment of head and leg elevation.

Medical Necessity Determination

General hospital-bed medical necessity

Hospital-bed requests are evaluated individually and case by case. The requested equipment must meet the applicable clinical criteria and must not be replaceable by a less costly suitable alternative.

ALL of the following

Clinical need: The member has a clinical need for hospital-bed positioning, elevation, specialized attachment, mobility support, or safety that cannot be adequately met by an ordinary bed or less costly suitable alternative.
Medical purpose: The requested bed is needed for treatment of the member's illness or injury and is not equipment used primarily and customarily for a nonmedical purpose.
An ordinary bed is generally useful in the absence of illness, injury, or disability.
No duplication: The request is not duplicative; the member does not already have a hospital bed that meets the member's medical needs.

Documentation Requirements

Prior Authorization

Submit complete supporting documentation

Submit a complete PA request for every hospital bed with clinical records supporting medical necessity for the requested bed type, a written prescription, and a letter of medical necessity signed by the prescribing provider. The prescription and letter must meet 130 CMR 409.416; use the MassHealth Prescription and Medical Necessity Review Form for Hospital Beds.

Documentation Required

Document the requested equipment’s specific criteria

Documentation must address the criteria applicable to the requested equipment type, including positioning and elevation, variable height, position-change frequency, control operation, transfer needs, weight, pediatric safety risk, and alternative-treatment information as applicable.

Not Covered

The following are not covered: ordinary beds used primarily for nonmedical purposes; hospital beds when documentation is insufficient to establish medical necessity for treatment of the member’s illness or injury; hospital beds when the therapeutic benefit can be achieved with a less costly alternative, such as pillows or wedges; and duplicate hospital beds 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 TypeRevisionsupersedes December 15, 2010 policy

Effective DateJuly 1, 2019

Next Review DateN/A

Key ActionSubmit prior authorization for every hospital-bed request with a prescription, signed letter of medical necessity, and supporting clinical documentation.

SourceLink

On This Page

Less costly alternatives, such as wearing a protective helmet, were tried and were unsuccessful or are contraindicated.

DocumentationThe request must document at least one fixed-height criterion and the member’s weight in the applicable range.

Extra-heavy-duty, extra-wide bed weight

Weight thresholdThe member’s weight exceeds 600 pounds.

Underlying criterionThe member must meet at least one criterion for a fixed-height hospital bed.

DocumentationThe request must document at least one fixed-height criterion and a member weight greater than 600 pounds.

The prescription and letter of medical necessity must meet the requirements of 130 CMR 409.416.

Prior Authorization

PA Submission Method

Submit PA requests electronically whenever possible. Use the appropriate Prior Authorization Request Type in the LTSS Provider Portal, or submit a non-electronic PA-1 request with all pertinent supporting documentation.

For a non-electronic request, mail the PA-1 form and supporting documentation to the address on the back of the PA-1 form.
Questions about portal access: LTSS Provider Service Center, (844) 368-5184 toll-free.

Documentation Required

Fixed-Height Bed Clinical Documentation

For a fixed-height hospital bed, document the member’s medical condition and the specific positioning, elevation, traction, or other hospital-bed need. The documentation must establish at least one applicable fixed-height criterion and, where relevant, explain the degree of elevation and prior attempts with pillows or wedges.

Positioning not feasible with an ordinary bed to alleviate pain; describe the required positioning and why a hospital bed is needed.
Head-of-bed elevation greater than 30 degrees most of the time due to a medical condition; document the condition, required degree of elevation, and attempts and results using pillows or wedges.
Traction or other equipment attachable only to a hospital bed; identify the equipment, its purpose, and the duration of use.
Elevation of the head or upper body less than 30 degrees does not usually require a hospital bed.

Documentation Required

Variable-Height Bed Documentation

A variable-height hospital-bed request must document at least one fixed-height hospital-bed criterion and the medical condition requiring variable height.

Explain why adjustable height is medically necessary for the member’s condition.

Documentation Required

Semi-Electric Bed Documentation

A semi-electric hospital-bed request must document at least one fixed-height criterion, the member’s frequent and/or immediate need to change body position, and the ability to operate the controls independently or with appropriate adaptive equipment.

Describe the medical condition requiring frequent or immediate position changes.
Document that the member can operate the controls independently, including use of adaptive equipment when applicable.
For a medically complex or neurologically impaired member, document the clinical appropriateness of a semi-electric bed if independent control is not otherwise established.

Documentation Required

Total-Electric Bed Documentation

A total-electric hospital-bed request must establish the variable-height and semi-electric medical-necessity requirements and show that total-electric functionality is the least costly medically appropriate alternative.

Document at least one fixed-height criterion, the need for variable height, and the frequent and/or immediate need for position changes.
Document the member’s ability to operate the controls independently, with adaptive equipment when appropriate, or the clinical appropriateness of a semi-electric bed for a medically complex or neurologically impaired member.
Document that the member is fully independent with transfers and requires adjustable height to transfer safely and independently.
Document that no other comparable medical equipment is available, suitable, and comparable in effect for the member.

Documentation Required

Heavy-Duty Bed Documentation

For a heavy-duty, extra-wide hospital bed, document at least one fixed-height hospital-bed criterion and that the member weighs more than 350 pounds but does not exceed 600 pounds.

Weight range: >350 pounds and <=600 pounds.

Documentation Required

Extra-Heavy-Duty Bed Documentation

For an extra-heavy-duty, extra-wide hospital bed, document at least one fixed-height hospital-bed criterion and that the member’s weight exceeds 600 pounds.

Weight requirement: >600 pounds.

Documentation Required

Pediatric Bed or Crib Without Enclosure

For a pediatric hospital bed or crib without an added safety enclosure, document medical necessity in accordance with the criteria for the applicable hospital-bed type.

Document the criteria for the applicable fixed-height, variable-height, semi-electric, total-electric, heavy-duty, or extra-heavy-duty hospital bed, as appropriate.

Documentation Required

Pediatric Bed or Crib With Safety Enclosure

For a pediatric hospital bed or crib with an added safety enclosure, document the applicable pediatric hospital-bed medical necessity, the member’s serious safety risk in an ordinary or standard hospital bed, and the failure or contraindication of less costly alternatives.

Document a medical condition placing the member at risk of falling out of or seriously injuring themself in an ordinary bed or standard hospital bed, such as cognitive or communication impairment or severe behavioral disorder.
Document a history of unsafe mobility, such as climbing out of bed, and injuries or risk of injury occurring up to the request.
Describe the medical condition and clinical need for the safety enclosure.
Document less costly alternatives, such as a protective helmet, that were tried and were unsuccessful or contraindicated, including the results.

Denial Risk

Nonmedical Use, Insufficient Support, Alternatives, or Duplication

A hospital-bed request may be denied when the bed is primarily used for a nonmedical purpose, when documentation does not establish medical necessity, when less costly alternatives can achieve the therapeutic benefit, or when the requested equipment duplicates a hospital bed the member already has.

An ordinary bed generally useful without illness, injury, or disability is not a medical use.
Insufficient documentation to establish medical necessity for treatment of the member’s illness or injury is a denial risk.
If pillows, wedges, or another less costly alternative can achieve the therapeutic benefit, the hospital bed may not be medically necessary.
Do not request duplicative equipment when the member already has a hospital bed meeting their medical needs.

Denial Risk

Safety-Enclosure Criteria Not Established

A safety enclosure is not supported unless the documentation establishes a serious safety risk in an ordinary or standard hospital bed and shows that less costly alternatives were unsuccessful or contraindicated.

Document a medical condition and behavior involving unsafe mobility that places the member at risk for falling out of or sustaining serious injury in an ordinary or standard hospital bed.
Document the history of injuries or risk up to the request.
Document alternatives tried, such as a protective helmet, and explain why they were unsuccessful or contraindicated.

Denial Risk

Underlying Bed Criteria or Functional Requirements Not Met

Requests are at risk of denial when the foundational fixed-height criteria or the equipment-specific functional requirements are not established in the clinical record.

For variable-height beds, document a fixed-height criterion and the medical need for variable height.
For semi-electric beds, document a fixed-height criterion, frequent and/or immediate position-change needs, and control operation or clinically appropriate adaptive equipment.
For total-electric beds, document the variable-height and semi-electric requirements, safe independent transfers requiring adjustable height, and the absence of a comparable suitable alternative.
For heavy-duty or extra-heavy-duty beds, document a fixed-height criterion and the applicable weight range.
For pediatric beds or cribs, document the criteria for the applicable hospital-bed type; an enclosure additionally requires documented serious safety risk and unsuccessful or contraindicated less costly alternatives.

Semi-electric hospital bed

Equipment typeSemi-electric hospital bed.

Height adjustmentAllows manual adjustment of bed height.

Head and leg adjustmentAllows electric adjustment of head and leg elevation.

Total-electric hospital bed

Equipment typeTotal-electric hospital bed.

Height adjustmentAllows electric adjustment of bed height.

Head and leg adjustmentAllows electric adjustment of head and leg elevation.

Pediatric hospital bed

Equipment typeA pediatric hospital bed may be manual, semi-electric, or total-electric.

Side enclosureMay include a safety device such as a 360-degree side enclosure.

Other safety optionsMay include another safety device in place of or in addition to the 360-degree side enclosure.

Pediatric crib

Equipment typeA pediatric crib is a hospital-grade bed.

Safety enclosureMay include an added safety enclosure.

Bed classificationIt is identified as a hospital-grade pediatric bed rather than an ordinary furniture bed.

Ordinary bed

Furniture classificationAn ordinary bed is typically sold as a furniture item.

Hospital-bed distinctionIt does not meet the definition of a hospital bed.

DME distinctionIt does not meet the definition of durable medical equipment (DME).

Pediatric safety enclosure medical necessity

A pediatric safety enclosure requires all of the following:

ALL of the following

Qualifying medical and safety risk: The member has a medical condition that puts the member at risk for falling out of or seriously injuring themself 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, such as climbing out of bed, that puts the member at risk for serious injury while in an ordinary bed or standard hospital bed.
Less costly alternatives, such as wearing a protective helmet, were tried and were unsuccessful or are contraindicated.