CurrentUnitedHealthcarePolicy CS181KY.09

Beds Mattresses Ky Cs

State-specific UnitedHealthcare medical policy (Kentucky) governing coverage of hospital beds, pediatric cribs, support surfaces, and related accessories. Coverage is determined using InterQual CP: Durable Medical Equipment criteria and applicable federal/state/contractual requirements.

Policy Summary

PayerUnitedHealthcare

PolicyBeds Mattresses Ky Cs

Policy CodePolicy CS181KY.09

Change TypeRevised supporting information (FDA section)

Effective DateMay 1, 2025

Next Review Date

Key ActionProviders must document that medical necessity criteria are met per InterQual CP: Durable Medical Equipment (Hospital Beds, Cribs, and Accessories; Support Surfaces) when requesting coverage.

SourceLink

POLICY UPDATE CHANGES

Updated FDA section to reflect the most current information.

InterQual-guidedCoverage determinations

Kentucky-onlyGeographic scope

~30HCPCS codes referenced

Coverage Summary

This policy (Policy Number: CS181KY.09) addresses coverage of hospital beds and mattresses (Kentucky). It is effective May 1, 2025 and applies specifically to members in the state of Kentucky.

Coverage determinations are InterQual-guided: medical necessity is determined using InterQual CP: Durable Medical Equipment clinical criteria for hospital beds, cribs, accessories, and support surfaces. The policy references approximately ~30 HCPCS codes (examples include E0193, E0250, E0265, E0277, E0316) for coverage/billing reference.

Medical-Necessity Criteria

Indications for Coverage / Medical Necessity

Coverage is determined when InterQual CP: Durable Medical Equipment criteria are met; refer to InterQual for specific clinical coverage criteria.

ALL of the following

Member is in Kentucky (policy applies only to the state of Kentucky).
Medical necessity is established per InterQual CP: Durable Medical Equipment - Hospital Beds, Cribs, and Accessories and/or InterQual CP: Durable Medical Equipment - Support Surfaces.
Federal, state, or contractual requirements for benefit plan coverage are satisfied (those requirements govern in event of conflict).

Coding

Hospital bed & mattress HCPCS codes (referenced for coverage/billing)HCPCS

E0193	Powered air flotation bed (low air loss therapy)
E0194	Air fluidized bed
E0250	Hospital bed, fixed height, with any type side rails, with mattress
E0251	Hospital bed, fixed height, with any type side rails, without mattress
E0255	Hospital bed, variable height, hi-lo, with any type side rails, with mattress
E0256	Hospital bed, variable height, hi-lo, with any type side rails, without mattress
E0260	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress
E0261	Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress
E0265	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress
E0266	Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress

1–10 of 33

1/4

Safety enclosure coding noteHCPCS

E0316

Safety enclosure with beds (e.g., Posey) should be coded with HCPCS code E0316

Billing Rule

Code safety enclosure as E0316

Safety enclosures (e.g., Posey) used with beds should be billed with HCPCS E0316.

Affected code: E0316

Provider Actions

Documentation Required

Use InterQual criteria for medical necessity determination

Providers must document that medical necessity criteria are met per InterQual CP: Durable Medical Equipment (Hospital Beds, Cribs, and Accessories; Support Surfaces) when requesting coverage.

Documentation Required

Follow federal/state/contractual requirements

Providers must ensure coverage requests comply with applicable federal, state (Kentucky), or contractual requirements, which govern in case of conflict with this policy.

Background

This UnitedHealthcare Medical Policy provides guidance for interpreting UnitedHealthcare standard benefit plans for hospital beds and support surfaces in Kentucky. When deciding coverage, applicable federal, state, or contractual requirements govern in the event of a conflict and should be checked before using this policy.

The policy directs readers to InterQual CP as the primary clinical criteria source for medical necessity determinations for Hospital Beds, Cribs, and Accessories and for Support Surfaces.

U.S. Food and Drug Administration material on hospital bed entrapment (Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment) is cited for informational purposes only and FDA approval alone is not a basis for coverage.

InterQual CP: Durable Medical Equipment — Proprietary clinical criteria used by UnitedHealthcare to determine medical necessity for durable medical equipment, including hospital beds and support surfaces.