CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Support Surfaces

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These guidelines describe the clinical information MassHealth uses to determine medical necessity for support surfaces requiring prior authorization. They apply to providers requesting support surfaces for MassHealth members, with approval determined individually and subject to applicable MassHealth and managed-care requirements.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Support Surfaces

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2004

Last ReviewApr 1, 2006

Next Review DateN/A

Key ActionSubmit and obtain approval of a new or updated Prior Authorization Request before the current authorization expires to continue using a support surface.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Pressure-ulcer stages recognized

7Conservative treatment requirements

8Medical-evaluation documentation components

>5% / >10%Weight-change thresholds

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Support Surfaces

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.

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Support Surfaces

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2004

Last ReviewApr 1, 2006

Next Review DateN/A

Key ActionSubmit and obtain approval of a new or updated Prior Authorization Request before the current authorization expires to continue using a support surface.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Pressure-ulcer stages recognized

7Conservative treatment requirements

8Medical-evaluation documentation components

>5% / >10%Weight-change thresholds

7Not-medically-necessary circumstances

Clinical Coverage Criteria

MassHealth bases medical-necessity determinations for support surfaces on a combination of clinical data and indicators affecting the relative risks and benefits of the product. Support surfaces are medically necessary when <strong>all</strong> of the following criteria are met:

ALL of the following

One or more pressure ulcers
- The member presents with a Stage 1 pressure ulcer: an observable pressure-related alteration of intact skin compared with the adjacent or opposite area, which may include changes in skin temperature, tissue consistency, or sensation. The ulcer appears as a defined area of persistent redness in lightly pigmented skin; in darker skin tones, it may appear with persistent red, blue, or purple tones.
- The member presents with a Stage 2 pressure ulcer: partial-thickness skin loss involving the epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
- The member presents with a Stage 3 pressure ulcer: full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, the underlying fascia. The ulcer presents clinically as a deep crater, with or without undermining of adjacent tissue.
- The member presents with a Stage 4 pressure ulcer: full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule. Undermining and sinus tracts may also be associated with Stage 4 ulcers.
A comprehensive medical history and physical examination have been conducted to determine factors contributing to the pressure ulcers.
Risk factors for developing pressure ulcers have been identified and documented, including, but not limited to, impaired mobility due to neurologic disease or injury, fractures, pain, restraints, or being bedridden or chairbound for at least 18 hours a day; complete immobility, defined as inability to change body position without assistance; limited mobility, defined as inability to independently change body position sufficiently to alleviate pressure; altered sensation or response to discomfort due to degenerative neurologic disease, cerebrovascular disease, central nervous system injury, depression, or drugs that adversely affect alertness; involuntary weight loss or gain greater than 5% in 30 days or greater than 10% in the previous 180 days resulting from protein-calorie undernutrition or edema; bowel and/or bladder incontinence; and comorbid conditions affecting independent functioning or healing, including peripheral vascular disease, vasculitis and other collagen vascular disorders, diabetes mellitus, end-stage disease, congestive heart failure, immune deficiency states, malignancies, malnutrition, dehydration, drugs affecting skin healing, depression, psychosis, and contractures at major joints.
- Conservative treatment requirements
  - Frequent turning and positioning to reduce pressure and prevent wound formation.
  - Appropriate management of moisture or incontinence.
  - Nutritional assessment and intervention consistent with the overall care plan to promote wound healing.
  - General protocols for wound debridement of Stage 2 through Stage 4 ulcers.
  - Weekly documented assessment by a physician, nurse, or licensed practitioner.
  - Education of wound-care staff, home caregivers, and the member regarding prevention and management of pressure ulcers.

Support surfaces are not medically necessary when a medical history and physical examination have been performed and other alternatives have been identified to minimize the risk of pressure ulcers. They are also not medically necessary when used to treat anatomical structural problems, neurological problems, pain management, morbid obesity, or comorbid conditions when no pressure ulcers are present.

Support surfaces are not medically necessary when one or more ulcers are present but the member is able to independently make changes in body position.

Air-fluidized beds are not medically necessary when used as palliative care or to treat coexisting pulmonary disease.

Support surfaces are not medically necessary when no medical history has been taken and/or there is no documentation justifying the need for the support surface.

Support surfaces may not be used in place of an established wound-care treatment plan.

Before placing a member on an air-fluidized bed, conservative treatment must have failed and the physician must have considered, and ruled out, all other alternative equipment.

Clinical Thresholds

Involuntary weight change

30-day thresholdGreater than 5% involuntary weight change in 30 days

180-day thresholdGreater than 10% involuntary weight change in the previous 180 days

Clinical contextThe weight change must result from protein-calorie undernutrition or edema.

Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Submission

Submit a prior authorization request with clinical documentation that supports the medical necessity of the requested support surface. Include the applicable request forms, medical-necessity information, and a written prescription as specified below.

Clinical documentation must support medical necessity.
Use the MassHealth Medical Necessity Review Form for Support Surfaces with the Prior Authorization Request form.
Include a written prescription signed by a licensed physician or nurse practitioner.

Prior Authorization

Renew Before Authorization Expires

To continue using a support surface, obtain approval of a new or updated Prior Authorization Request before the current authorization expires.

Submit the renewal request early enough for review before the current authorization expiration date.

Support Surface Overview

Support surfaces include mattresses, mattress replacements, overlays, and seat cushions designed to manage tissue loads, microclimate, or other therapeutic functions. Examples include nonpowered air, foam, gel, or water surfaces; powered or advanced nonpowered surfaces; low-air-loss and dynamic-air overlays; whole-bed systems; high-air-loss or air-fluidized beds; and seating cushions. Members with evidence of pressure ulcers are the primary candidates, and medical necessity is determined from clinical data and indicators affecting the relative risks and benefits of the requested product on an individual, case-by-case basis.

Key Terms

Pressure ulcer

DefinitionAny lesion caused by unrelieved pressure resulting in damage to underlying tissues located over a bony prominence.

Support surface

DefinitionA mattress, mattress replacement, overlay, or seat cushion designed for management of tissue loads, microclimate, or other therapeutic functions.

ExamplesProducts may include nonpowered air, foam, gel, or water surfaces; powered or advanced nonpowered surfaces; high-air-loss systems such as air-fluidized beds; and seating cushions.

Pressure-ulcer stages

Stage 1Observable pressure-related alteration of intact skin; indicators may include changes in skin temperature, tissue consistency, or sensation, with persistent redness or red, blue, or purple tones.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Support Surfaces

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 1, 2004

Last ReviewApr 1, 2006

Next Review DateN/A

Key ActionSubmit and obtain approval of a new or updated Prior Authorization Request before the current authorization expires to continue using a support surface.

SourceLink

On This Page

Documentation of the care plan in the member's medical record.

Documentation Required

Consider Alternatives Before an Air-Fluidized Bed

Before placing a member on an air-fluidized bed, conservative treatment must have failed and the physician must consider and rule out all other alternative equipment.

Document failure of conservative treatment.
Document that all other alternative equipment was considered and ruled out by the physician.

Documentation Required

Required Clinical Documentation

The most recent medical evaluation must provide the clinical information needed to establish medical necessity for the requested support surface.

Primary wound diagnosis name and ICD-CM code specific to the condition for which the support surface is requested.
Secondary comorbid diagnosis name and ICD-CM code.
Wound location, length, width, depth, drainage, color, and photographs; photographs should show adequate lighting and a measuring device alongside the wound.
Comprehensive medical history and physical examination.
Pressure-ulcer/wound risk factors using the Braden or Norton scale.
Relevant laboratory indicators.
Wound-care plan and treatment outcomes.
Type and estimated duration of need for the support surface.

Unsupported block type: documentation

Documentation Required

Include a Signed Prescription

A written prescription signed by a licensed physician or nurse practitioner must accompany the prior authorization forms.

The prescription is required under 130 CMR 409.407(B) and Durable Medical Equipment Bulletin 13.

Denial Risk

Insufficient Justification or Inappropriate Use May Result in Denial

MassHealth may deny support-surface coverage when the request lacks adequate clinical justification, the equipment is used inappropriately, or required alternatives have not been addressed.

No medical history or documentation justifies the need for the support surface.
Support surfaces are used instead of a wound-care treatment plan.
Support surfaces are used for anatomical structural problems, neurological problems, pain management, morbid obesity, or a comorbid condition when no pressure ulcer is present.
A member with one or more ulcers can independently change body position.
Conservative treatment failed, but the physician did not consider and rule out all alternative equipment before using an air-fluidized bed.
A medical history and physical examination were performed and other alternatives to minimize pressure-ulcer risk were identified.

Denial Risk

Air-Fluidized Bed Excluded Uses

An air-fluidized bed is not medically necessary when it is used for palliative care or to treat coexisting pulmonary disease.

Do not request or use an air-fluidized bed for these excluded purposes.

Prior Authorization

Do Not Continue Without Renewed Authorization

Continuing a support surface after the current authorization expires without an approved new or updated Prior Authorization Request is not permitted.

Submit and obtain approval of the new or updated request before the existing authorization expires.
Do not continue authorized use past the expiration date without renewed approval.

Stage 2Partial-thickness skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may appear as an abrasion, blister, or shallow crater.

Stage 3Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue, potentially extending to but not through the underlying fascia; it may present as a deep crater.

Stage 4Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures such as a tendon or joint capsule.