CurrentnorthwoodPolicy N/A

Pressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)

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This policy governs coverage and medical necessity criteria for air-fluidized beds (HCPCS E0194) used to treat stage 3–4 pressure ulcers and specifies documentation, denial reasons, and monthly recertification requirements for members receiving the device.

Policy Summary

Payernorthwood

PolicyPressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2021

Last ReviewDec 9, 2020

Next Review DateDec 9, 2020

Key ActionObtain and retain a monthly written treating practitioner statement certifying continued medical necessity; add KX modifier only when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Stage 3 or 4Ulcer stage required for coverage

MonthlyPractitioner recertification interval

E0194HCPCS code

KXRequired modifier

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CurrentnorthwoodPolicy N/A

Pressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)

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Policy Summary

Payernorthwood

PolicyPressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2021

Last ReviewDec 9, 2020

Next Review DateDec 9, 2020

Key ActionObtain and retain a monthly written treating practitioner statement certifying continued medical necessity; add KX modifier only when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Stage 3 or 4Ulcer stage required for coverage

MonthlyPractitioner recertification interval

E0194HCPCS code

KXRequired modifier

6 monthsACA face-to-face

Coverage Criteria for Air-Fluidized Bed (Group 3 Support Surface)

Initial Coverage Criteria

Covered when ALL of the following are met

Initial Coverage Requirements: 1. The member has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure ulcer.

Mobility: 2. The member is bedridden or chair bound as a result of severely limited mobility.

Institutionalization: 3. In the absence of an air-fluidized bed, the member would require institutionalization.

Order and assessment: 4. The air-fluidized bed is ordered in writing by the member's treating practitioner based upon a comprehensive assessment and evaluation of the member after completion of a course of conservative treatment; the evaluation generally must be performed within one month prior to initiation of therapy with the air-fluidized bed.

Conservative treatment: 5. At least one month of conservative treatment without progression toward wound healing; conservative treatment must include: (a) frequent repositioning (usually every 2 hours), (b) use of a Group 2 support surface, (c) necessary treatment to resolve any wound infection, (d) optimization of nutrition status, (e) debridement by any means (including wet-to-dry gauze dressings), and (f) maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering when necessary.>= 1 month

An occlusive barrier is required when necessary to maintain a moist wound-healing environment; if moist dressings are not required because of wound characteristics (e.g., heavily exudative wound), the occlusive barrier is not required. Wet-to-dry dressings used for debridement begun during conservative treatment and continued beyond 30 days do not preclude coverage.

Conservative treatment - additional measures: Conservative treatment should generally also include beneficiary and caregiver education, at least weekly assessment by the treating practitioner, nurse, or other licensed healthcare practitioner, and appropriate management of moisture/incontinence.

Caregiver availability: 6. A trained adult caregiver is available to assist with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system.

Monthly recertification: 7. The treating practitioner directs the home treatment regimen and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis.monthly

Continued coverage must be documented monthly until the ulcer heals or the care plan is modified to promote healing.

Alternatives considered: 8. All other alternative equipment has been considered and ruled out.

DME Medical Necessity Criteria

Coverage determinations are made on a case-by-case basis and require documentation of medical necessity consistent with contract language and applicable NCD/LCD.

General coverage logic: Coverage requires: (1) documentation from the treating practitioner describing the medical condition and estimated length of need, (2) completion of the Group 3 Statement by the treating practitioner (not completed by the DME supplier), and (3) consistency with the member's contract terms and any applicable CMS NCD/LCDs.

The treating practitioner statement lists specific clinical conditions and estimated length of need; supplier must obtain required documentation prior to delivery when ACA 6407 face-to-face documentation applies.

Documentation and practitioner assessment timing: Treating practitioner evaluation generally must be performed within one month prior to initiation of therapy; when ACA 6407 applies, a face-to-face examination within six months prior to the written order must be documented and received prior to delivery.

Supplier must retain required documentation on file; failure to provide required face-to-face documentation may lead to denial.

Monthly treating practitioner certification: Supplier must retain a monthly written statement from the treating practitioner documenting ulcer size, care plan modifications if the ulcer is not healing, and that continued use of the air-fluidized bed is medically necessary; use of the KX modifier is permitted only when all policy criteria are met and the monthly certification supports continued need.

Payment for an air-fluidized bed does not include payment for caregiver services or for architectural adjustments such as electrical or structural improvements. These costs are excluded from coverage and should not be billed as part of the DME supply. The policy further states that claims will be denied as not reasonable and necessary if the stated coverage criteria are not met.

Equipment that is used primarily and customarily for a non-medical purpose is not considered durable medical equipment and is excluded from coverage. When an item’s main function is non‑medical, it should not be billed under DME benefits.

An air‑fluidized bed will be denied as not reasonable and necessary for members with contraindications including: (1) coexisting pulmonary disease (which can make coughing ineffective and thicken secretions due to dry air inhalation); (2) need for unprotected wet soaks or moist dressings (i.e., dressings not covered by an occlusive barrier); (3) a caregiver who is unwilling or unable to provide required care; (4) inadequate structural support in the residence to safely accommodate the bed (the system can weigh approximately 1600 pounds or more); (5) an insufficient electrical system to handle increased energy consumption; or (6) any other known contraindications. If any of these conditions exist, the device will be denied.

The policy expressly excludes all ICD‑10 diagnosis codes not listed in the 'ICD‑10 Codes That Support Medical Necessity' section from coverage. This exclusion was noted in the revision history and means that unlisted diagnosis codes should be treated as not covered for the purposes of air‑fluidized bed medical necessity determinations.

Coding — HCPCS and ICD-10 Guidance

Covered HCPCS Level II CodesHCPCSCovered

E0194

AIR FLUIDIZED BED

ICD-10 codes that support medical necessity (stage 3 and 4 pressure ulcers)ICD-10Covered

L89.003	Pressure ulcer of unspecified elbow, stage 3
L89.004	Pressure ulcer of unspecified elbow, stage 4
L89.013	Pressure ulcer of right elbow, stage 3
L89.014	Pressure ulcer of right elbow, stage 4
L89.023	Pressure ulcer of left elbow, stage 3
L89.024	Pressure ulcer of left elbow, stage 4
L89.103	Pressure ulcer of unspecified part of back, stage 3
L89.104	Pressure ulcer of unspecified part of back, stage 4
L89.113	Pressure ulcer of right upper back, stage 3
L89.114	Pressure ulcer of right upper back, stage 4

1–10 of 49

1/5

ICD-10 codes that do not support medical necessityICD-10Not Covered

No codes listed

Conservative treatment duration — >= 1 month

Required conservative treatment durationAt least 1 month of conservative treatment without progression toward wound healing

What conservative treatment includesFrequent repositioning (usually every 2 hours); use of a Group 2 support surface; treatment of wound infection; nutrition optimization; debridement as needed; maintenance of a clean, moist wound bed with appropriate moist dressings and occlusive covering when necessary

Evaluation timingComprehensive assessment and evaluation generally performed within one month prior to initiation of air-fluidized bed therapy

Provider Actions — Prior Auth, Documentation, and Clinical Requirements

Prior Authorization

Prior authorization / KX modifier – E0194 covered only when criteria and documentation on file

Air‑fluidized bed (HCPCS E0194) is covered only when all policy criteria are met and the supplier retains required documentation; add the KX modifier only when initial and monthly criteria are satisfied.

Initial claim: add KX only if all criteria in this policy have been met.
Subsequent monthly claims: add KX only if the treating practitioner's monthly certification indicates continued medical necessity.
Discontinue KX if criteria are not met or use is discontinued.

Note

Case-by-case coverage; documentation timing per contract and medical necessity

Coverage decisions are made case‑by‑case and are governed by the member's contract, medical necessity requirements, and applicable CMS NCDs/LCDs; required documentation must be received prior to delivery for items subject to ACA 6407.

Medical Necessity Details and Treating Practitioner Statements

Practitioner-stated clinical indications

Treating practitioner should indicate any of the following conditions (circle all that apply); if none apply, attach separate documentation describing medical necessity:

Clinical conditions listed on practitioner statement: 1. Completely immobile; 2. Limited mobility; 3. Any pressure ulcer on the trunk or pelvis; 4. Impaired nutritional status; 5. Fecal or urinary incontinence; 6. Altered sensory perception; 7. Compromised circulatory status. Estimated length of need (months) must be provided (99 = lifetime).

If none of the above apply, a separate sheet documenting medical necessity must be attached.

Rental and Purchase Rules

HCPCS / Product	Rental vs Purchase	Notes / Payment exclusions
E0194 — AIR FLUIDIZED BED	Not specified in policy text	Policy lists HCPCS E0194 and notes that payment does not include caregiver services or architectural adjustments (electrical or structural improvements).
(Product description: air-fluidized bed; ceramic bead bed)		Continued coverage must be documented monthly by the treating practitioner; continued use is covered until ulcer heals or documentation supports continued need or changes to care plan. Rental vs purchase not stated in provided policy text.

Item / Category	Rental vs Purchase	Contract/coverage note
Group 3 support surfaces	Not specified in policy text	Whether an item is covered, excluded, or limited is defined by the member's contract; policy criteria and contract terms determine coverage. No explicit rental versus purchase rule is provided in the cited policy text.

Replacement and Continuation Rules

Air-fluidized bed — N/A (coverage continues monthly as medically necessary)

Replacement interval for air-fluidized bed (E0194)N/A — continued coverage is documented monthly and continues as medically necessary until the ulcer heals or care plan changes justify discontinuation

Monthly recertification requirementTreating practitioner must reevaluate and recertify need monthly to support continued coverage

Denial triggers relevant to continued coverageContinued use may be denied if contraindications develop (e.g., coexisting pulmonary disease, caregiver unable/unwilling, inadequate structural/electrical support)

Group 3 support surfaces — replacement/renewal notes

Replacement/renewal documentationSupplier must retain monthly written statements from the treating practitioner documenting ongoing need; this documentation supports continued replacement/renewal decisions

Documentation Requirements and Supplier Responsibilities

Documentation Required

Monthly treating practitioner certification retained by supplier; KX modifier used only when criteria are met

Supplier must retain the treating practitioner's monthly certification on file and use the KX modifier only when the initial and monthly policy criteria are met and the monthly certification supports continued need.

Monthly certification must be on file and available for inspection.
KX modifier: use on initial and subsequent claims only when documentation verifies that all policy criteria and monthly recertification are met; discontinue when criteria lapse.

Documentation Required

Face‑to‑face exam within 6 months prior to order when required (ACA 6407)

When ACA 6407 applies, the treating practitioner must have performed a face‑to‑face examination during the six‑month period preceding the written order; documentation must be provided to the supplier prior to delivery.

Face‑to‑face exam requirement applies to items subject to ACA 6407 and must occur within six months before the written order.

Not Covered / Exclusions

Any ICD‑10 codes not explicitly listed in the policy’s "support medical necessity" section are considered not covered. Additionally, coverage will be denied for situations described as contraindications—such as coexisting pulmonary disease, need for unprotected moist dressings/wet soaks, lack of an appropriate caregiver, or inadequate structural/electrical support—or other conditions where the air‑fluidized bed does not meet the stated medical necessity criteria.

Devices and equipment that are used primarily for non‑medical or customary non‑medical purposes are not considered DME and are not covered under this policy. Determination of coverage requires that the item’s principal use be medical; items with primarily non‑medical use should not be billed as DME.

Background — Technology and Purpose

An air‑fluidized bed operates by circulating warm, pressurized air through a bed of ceramic beads to simulate fluid movement. This process redistributes pressure, reduces shear, and helps maintain a dry, protected wound environment to treat and prevent pressure ulcers and to manage extensive burns. The bed’s design and intended clinical use distinguish it from non‑medical bedding products and place it within the Group 3 pressure‑reducing support surface category.

Definitions

Air-fluidized bed definition

Basic definitionAir-fluidized bed: a bed filled with ceramic beads through which warm pressurized air circulates to simulate fluid movement and redistribute pressure

Mechanism and componentsContains up to ~2000 pounds of ceramic beads covered by a polyester sheet; warm pressurized air flows through the beads creating a 'floating' sensation and distributing weight over a large surface area

Clinical purposeMarketed to treat and prevent pressure sores and to manage extensive burns by maintaining a dry, protected wound environment and reducing pressure and shear

Pressure ulcer staging definitions — Stages 1–4, Unstageable, Deep Tissue (NPUAP 2016)

Stage 1 Pressure InjuryNon-blanchable erythema of intact skin; may include changes in sensation, temperature, or firmness

Stage 2 Pressure Injury

Revision and Authorization History

2006-11-20initial_release

Initial release of the Pressure Reducing Support Surfaces - Group 3 policy.

2008-12icd9_update

Added ICD-9 codes 707.23 and 707.24 and referenced NPUAP guidelines for pressure ulcer staging.

2009-12-22annual_review

Series of annual reviews and updates beginning in December 2009; multiple annual reviews noted including updates to references and coverage language through 2015.

Policy Summary

Payernorthwood

PolicyPressure Reducing Support Surfaces - Group 3 (Air-fluidized bed)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMay 1, 2021

Last ReviewDec 9, 2020

Next Review DateDec 9, 2020

Key ActionObtain and retain a monthly written treating practitioner statement certifying continued medical necessity; add KX modifier only when criteria are met.

SourceLink

On This Page

Monthly certification must be available for inspection and is required for ongoing coverage.

Contraindications and denial risks: Air-fluidized bed will be denied as not reasonable and necessary if contraindications are present (e.g., coexisting pulmonary disease, need for unprotected moist dressings/wet soaks, unwilling/unavailable caregiver, inadequate structural or electrical support) or if required documentation is not provided.

Any ICD-10 code not listed in the policy's supporting codes will not support medical necessity.

Final benefit determinations depend on the member's contract terms (coverage, exclusions, limits).

Northwood follows applicable CMS NCDs/LCDs when applying medical policy.

Step Therapy

Prerequisite: ≥1 month of conservative treatment before coverage

At least one month of conservative treatment without progression toward wound healing is required before initiating an air‑fluidized bed; conservative measures must include frequent repositioning and use of a Group 2 support surface among other interventions.

Conservative treatment must be at least one month in duration.
Required elements include: frequent repositioning (usually every 2 hours); use of a Group 2 support surface; infection treatment; nutrition optimization; debridement as needed; maintenance of a clean, moist wound bed with appropriate dressings.

Note

Provider action placeholder

(No content — placeholder block in source had no additional provider action beyond existing documentation and criteria.)

Documentation Required

Monthly treating practitioner certification retained by supplier; KX used only when criteria met

Supplier must retain a monthly written statement from the treating practitioner documenting ulcer size, care‑plan changes if not healing, and that continued bed use is medically necessary; add KX only when the monthly certification supports continued need.

Monthly statement must specify ulcer size, what care‑plan changes are being made if ulcer not healing, and that continued use is medically necessary for wound management.
Supplier must keep the monthly treating practitioner statement on file and available for inspection.
Use KX on initial and subsequent claims only when the policy criteria and monthly certification are met; discontinue KX when criteria are not met.

Documentation Required

ACA 6407: face‑to‑face exam within 6 months before order when required

When ACA 6407 applies, the treating practitioner must have conducted a face‑to‑face exam during the six‑month period preceding the written order and that documentation must be received by the supplier prior to delivery.

Face‑to‑face exam must occur within the six months prior to the written order.
Supplier must receive the documentation before delivery for DME items subject to ACA 6407.

Documentation Required

Treating practitioner must complete and sign Group 3 Statement and document condition/length of need

Documentation must describe the medical condition for which the DME is prescribed; for Group 3 surfaces the treating practitioner must complete and sign the provided Statement form indicating applicable clinical conditions and estimated length of need.

Statement of Treating Practitioner form must be completed by the treating practitioner (not the DME supplier) and include clinical conditions and estimated length of need.
Documentation must describe the medical condition for which the device is prescribed and be consistent with contract and CMS NCD/LCD requirements.
Supplier must obtain required documentation prior to delivery when ACA 6407 applies.

Denial Risk

Denial triggers and contraindications — claims denied if criteria or contraindications present

Claims will be denied as not reasonable and necessary if the stated coverage criteria are not met; claims are also denied when specified contraindications exist (e.g., coexisting pulmonary disease, need for unprotected moist dressings, unwilling/unable caregiver, inadequate structural or electrical support).

Denial if coverage criteria are not met.
Denial triggers include: coexisting pulmonary disease; requirement for unprotected wet soaks/moist dressings; caregiver unwilling/unable; inadequate structural support; insufficient electrical system; other known contraindications.

Denial Risk

ACA 6407 documentation risk — missing face‑to‑face exam within required timeframe may cause denial

If ACA 6407 applies and no documentation of a treating practitioner face‑to‑face exam within the six months prior to the written order is provided, the claim may be denied because the documentation must be received prior to delivery for certain DME items.

Failure to provide required face‑to‑face documentation within six months before the order is a risk for denial.
Required documentation must be received by the supplier prior to delivery when ACA 6407 applies.

Estimate of length of need

Treating practitioner statement must include estimated length of need (months; 99 = lifetime) on the Group 3 form

Who completes the formThe Statement of Treating Practitioner must be completed and signed by the treating practitioner; it may NOT be completed by the DME supplier or anyone in a financial relationship with the supplier

Contract and NCD/LCD considerationsWhether an item is covered, excluded, or limited is defined by the member's contract and applicable NCD/LCDs — replacement/renewal decisions follow those terms in addition to medical documentation

Supplier must receive the documentation prior to delivery.

Documentation Required

Treating practitioner must complete and sign Group 3 Statement form; supplier must obtain documentation prior to delivery when ACA 6407 applies

The treating practitioner must complete and sign the Statement of Treating Practitioner for Group 3 Support Surfaces; the form must not be completed by the DME provider and must include the clinical conditions and estimated length of need; supplier must obtain this documentation prior to delivery when ACA 6407 applies.

Form must be completed and signed by the treating practitioner (not by the DME provider or anyone in a financial relationship with the provider).
Form must indicate applicable clinical conditions (e.g., immobility, pressure ulcers, impaired nutrition) and estimated length of need.
Supplier must obtain required documentation prior to delivery for items subject to ACA 6407.

Partial-thickness skin loss with exposed dermis; wound bed viable, pink/red, moist; no adipose or deeper tissues visible

Stage 3 Pressure InjuryFull-thickness skin loss with visible adipose; granulation tissue, slough or eschar may be present; undermining/tunneling may occur

Stage 4 Pressure InjuryFull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone

Unstageable Pressure InjuryFull-thickness skin and tissue loss obscured by slough or eschar; true depth cannot be determined until debridement

Deep Tissue Pressure Injury (DTPI)Persistent non-blanchable deep red, maroon or purple discoloration or epidermal separation revealing a dark wound bed; may evolve rapidly to other stages

Statement of Treating Practitioner for Group 3 Support Surfaces — form details and required elements

Required elements on the Statement formIndicate mobility status, presence of any pressure ulcer on trunk/pelvis, impaired nutritional status, fecal/urinary incontinence, altered sensory perception, compromised circulatory status; provide estimated length of need

Signature and provider identificationPractitioner name (printed), signature, UPIN, and date are required on the form

Who may complete the formThe form must be completed and signed by the treating practitioner and may NOT be completed by the DME supplier or anyone in a financial relationship with the supplier

If none applyIf none of the listed conditions apply, attach a separate sheet documenting medical necessity for the item ordered

2016-12-08annual_review

Annual review completed with no changes noted in December 2016.

2017-12-18staging_update

Pressure ulcer staging criteria revised to reflect the NPUAP 2016 Staging Consensus Conference.

2018-12medicare_references_update

Annual review with Medicare references updated.

2019-12icd10_and_notation_update

Added ICD-10 codes and added notation excluding all unlisted diagnosis codes from coverage.

2020-12-09terminology_and_icd10_update

Revised terminology from 'physician' to 'treating practitioner' and updated ICD-10 coding; annual review completed.

2021-05-01effective_date_entry

Policy effective date recorded as May 1, 2021; NPUAP name changed to National Pressure Injury Advisory Panel in 2021 and NCD/LCD verbiage was added to the Important Note.

2021-12-07annual_review

Annual review completed December 7, 2021 with updates to Important Note and nomenclature.

2022-12-06annual_review

Annual review completed December 6, 2022 with no changes.

2023-12-04annual_review

Annual review completed December 4, 2023 with no changes.

2024-12-02annual_review

Annual review completed December 2, 2024 with no changes.

2025-12-08annual_reviewLatest

Annual review completed December 8, 2025 with no changes.