CurrentSelectHealthPolicy N/A

Hospital beds (DME) — Coverage Criteria

Defines medical necessity and coverage considerations for hospital beds (including variable height and pediatric beds) for SelectHealth members across Commercial, Medicare Advantage, and Medicaid plans; affects providers and DME suppliers requesting authorization or billing for hospital beds.

Policy Summary

PayerSelectHealth

PolicyHospital beds (DME) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 19, 1998

Next Review DateN/A

Key ActionVerify CMS/State coverage rules for Medicare Advantage and Medicaid members and use SelectHealth criteria when no CMS/State guidance exists.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E0328,E0329HCPCS codes listed for hospital beds

Applies to Medicare & MedicaidMedicare & Medicaid tie-ins

7/19/98Implementation

Coverage Criteria for Hospital Beds

Medical necessity criteria

Covered when ALL of the following are met

Primary justification: The condition requires positioning of the body in a manner not feasible in a standard bed (e.g., to alleviate pain, prevent contractures, or avoid secretions)

From 'Justification for use in the home'

Attachment requirement: Management of the condition requires attachments that cannot be applied to an ordinary special bed

Attachment capability cited as medical justification

Clinical scenarios where variable height or hospital bed features may be necessary: Severe cardiac conditions (where climbing into an elevated bed would be difficult due to worsening cardiac symptoms); severe arthritis or injuries to the lower extremities (patient needs to sit on edge of bed with feet on floor to assist ambulation); spinal cord injuries (including quadriplegia and paraplegia), multiple limb amputation, strokes

Policy Summary

PayerSelectHealth

PolicyHospital beds (DME) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 19, 1998

Next Review DateN/A

Key ActionVerify CMS/State coverage rules for Medicare Advantage and Medicaid members and use SelectHealth criteria when no CMS/State guidance exists.

SourceLink

On This Page

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Medical Necessity Details

DME medical necessity — Hospital beds

Hospital beds are medically justified when ALL of the following apply:

Positioning need: Condition requires positioning of the body in a manner not feasible in a standard bed (e.g., to alleviate pain, prevent contractures, or avoid secretions)

Primary justification (home use)

Clinical scenarios: Severe cardiac conditions (difficulty climbing into elevated bed due to worsening cardiac symptoms); severe arthritis or lower extremity injuries (needs to sit on edge of bed with feet on floor to assist ambulation); spinal cord injuries including quadriplegia and paraplegia; multiple limb amputation; strokes

Examples where variable height or attachments may be necessary

Attachment requirement: Management requires attachments that cannot be applied to an ordinary special bed

Supports need for hospital bed features

Continuing medical necessity should be regularly monitored at intervals appropriate to the patient's likely course of improvement; prognosis and expected course should be considered when determining rental versus purchase

Monitoring and purchase-vs-rental consideration

Provider Actions & Plan Alignment

Note

Follow CMS / State Rules

Coverage is determined by the Centers for Medicare and Medicaid Services (CMS). Follow CMS/State rules for Medicare Advantage and Medicaid. If CMS (or the applicable State Medicaid program) has not adopted a coverage determination and InterQual criteria are not available, SelectHealth commercial criteria apply.

Medicare: follow CMS determinations first; if none, use InterQual when available; otherwise use SelectHealth commercial criteria.
Medicaid (Utah): follow State Medicaid determinations first; if none, use InterQual when available; otherwise use SelectHealth commercial criteria.

Step Therapy

No step therapy requirements are specified for hospital beds in this policy. Do not impose step therapy; apply clinical criteria and documentation requirements instead.

Documentation Required

Clinical Justification & Periodic Reassessment

Document clinical justification that a standard bed cannot meet the patient's needs. The medical record must show the condition requires body positioning not feasible in a standard bed (for example, to alleviate pain, prevent contractures, avoid secretions, or allow safe transfers). Examples include severe cardiac conditions limiting ability to climb into an elevated bed, severe lower-extremity arthritis or injuries requiring sitting on the bed edge with feet on the floor to assist ambulation, spinal cord injuries (quadriplegia/paraplegia), multiple limb amputation, or stroke.

Must document why positioning in a standard bed is not feasible.
Provide diagnosis and functional limitations (e.g., inability to tolerate transfers, need for positioning to prevent contractures or manage secretions).
Include examples that support need: severe cardiac disease, severe arthritis/injury to lower extremities, spinal cord injury, multiple limb amputation, stroke.

Denial Risk

Continuing Medical Necessity Required

Continuing medical necessity must be documented and periodically reassessed. Failure to demonstrate ongoing need or to provide monitoring documentation may result in non-coverage or discontinuation of rental/purchase authorization. Reassess at intervals appropriate to the patient's expected course of improvement and consider prognosis and likelihood of benefit when deciding rental versus purchase.

Regular monitoring and documentation of continued need is required; specify reassessment interval in the medical record.
If continuing need is not demonstrated, coverage may be denied or terminated.
Weigh overall prognosis and expected longevity when authorizing purchase versus rental.

Background

Hospital beds are indicated when required patient positioning cannot be achieved in a standard bed. Examples cited include needs to alleviate pain, prevent contractures, or manage secretions. The policy specifically notes that variable height or attachment capability may be necessary for clinical scenarios such as severe cardiac conditions that impede climbing into an elevated bed, severe arthritis or lower extremity injuries where the patient needs to sit on the edge of the bed with feet on the floor to assist ambulation, spinal cord injuries, multiple limb amputation, and stroke. Continuing medical necessity should be reassessed at intervals appropriate to the patient’s expected course.

Definitions

Variable height hospital bed — definition / note

DefinitionVariable height hospital bed: bed with adjustable height to assist patient transfer/ambulation and accommodate clinical needs (used when positioning required for care cannot be achieved in a standard bed).

Primary indicationCondition requires positioning of the body in a manner not feasible in a standard bed (e.g., to alleviate pain, prevent contractures, or avoid secretions).

Clinical examples where variable height may be necessarySevere cardiac conditions (difficulty climbing into an elevated bed); severe arthritis or lower extremity injuries (needs to sit on edge of bed with feet on floor to assist ambulation); spinal cord injuries (including quadriplegia and paraplegia), multiple limb amputation, and strokes.

Attachment requirementManagement requires attachments that cannot be applied to an ordinary special bed, supporting need for hospital bed features such as variable height.

Place of useIntended for home use when required positioning cannot be achieved in a standard bed.

Equipment	Rental vs Purchase Rule
Hospital bed
Decision to rent versus purchase should consider continuing medical necessity and the patient’s prognosis for improvement and longevity; these factors should be weighed when determining purchase versus rental.

Replacement Rules

Hospital bed replacement — details not specified in source

Replacement interval specifiedNot specified in the policy text; replacement decisions should be based on continuing medical necessity and the patient’s course of improvement.

Consideration for purchase vs rentalOverall prognosis for improvement and longevity should be weighed when determining whether to purchase or rent a hospital bed for a specific beneficiary.

Continuing medical necessityContinuing medical necessity should be regularly monitored at intervals appropriate to the patient’s likely course of improvement and will affect replacement and purchase decisions.

Scope of Policy does not enumerate fixed replacement intervals; clinical reassessment drives replacement decisions.

Required Documentation

Documentation Required

Submit supporting clinical documentation

Provide supporting clinical notes that document the inability to achieve required positioning in a standard bed, the patient’s functional limitations, prognosis, and the plan and timing for periodic reassessment of ongoing need.

Describe positioning goals (e.g., alleviate pain, prevent contractures, manage secretions).
List relevant functional limitations and specific diagnoses (examples: severe cardiac disease, severe arthritis/lower extremity injury, spinal cord injury, multiple limb amputation, stroke).
Include prognosis and whether purchase versus rental is being considered based on expected course.

OpenPayer