CurrentUnitedHealthcarePolicy CS181PA.H

Beds and Mattresses (for Pennsylvania Only)

State-specific UnitedHealthcare medical policy (Pennsylvania) governing coverage of hospital beds, support surfaces, specialty beds, safety enclosures, and related accessories as durable medical equipment (DME), referencing InterQual CP criteria for medical necessity and listing applicable HCPCS codes.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for Pennsylvania Only)

Policy CodePolicy CS181PA.H

Change TypeSupporting information / FDA update

Effective DateJun 1, 2025

Next Review Date

Key ActionWhen requesting hospital beds, support surfaces, or safety enclosures, reference the InterQual CP: Durable Medical Equipment criteria and include supporting clinical documentation demonstrating applicable medical necessity criteria are met.

POLICY UPDATE CHANGES

Updated FDA section to reflect the most current information

1State-specific policy (Pennsylvania)

Safety enclosures covered with criteriaCovered Indication Summary

InterQual referencedClinical Criteria Source

Coverage Summary

This is a Pennsylvania-specific UnitedHealthcare medical policy (Policy Number CS181PA.H) that governs coverage of hospital beds, support surfaces, specialty beds, safety enclosures, and related accessories as durable medical equipment (DME) and references InterQual CP criteria for medical necessity.

Coverage stance is mixed: safety enclosures are covered as DME when specified criteria are met (see Safety Enclosure criteria). The policy requires referencing InterQual CP: Durable Medical Equipment for support surfaces and hospital beds, cribs, and accessories to determine medical necessity.

State-specific note: this policy applies only to Pennsylvania; requests that do not meet Pennsylvania Authority requirements (PARP) will be evaluated case-by-case and providers should reference Pennsylvania Code, Title 55, Chapter 1101 and any state/contractual requirements when requesting prior authorization.

HCPCS / DME Codes

Referenced HCPCS / DME CodesHCPCS

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

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Provider Actions

Documentation Required

Support documentation per InterQual criteria

When requesting hospital beds, support surfaces, or safety enclosures, reference the InterQual CP: Durable Medical Equipment criteria and include supporting clinical documentation demonstrating that the applicable medical necessity criteria are met. Examples of required documentation include: diagnosis, risk for skin breakdown, cognitive impairment or severe behavioral disorder, and documentation of prior trials of less intensive measures.

Diagnosis (e.g., traumatic brain injury, cerebral palsy, seizure disorder)
Risk for skin breakdown (preventive or therapeutic need for support surface)
Cognitive impairment or severe behavioral disorder documentation
Prior trials of less intensive measures and outcomes (e.g., mattress on floor, medical helmet, removal of hazards, side rails, weighted blankets)

Prior Authorization

Pennsylvania state-specific application

This policy applies only to Pennsylvania. Requests that do not meet PARP criteria will be evaluated case-by-case. When obtaining prior authorization, reference Pennsylvania Code Title 55, Chapter 1101 and any applicable state or contractual requirements.

Reference Pennsylvania Code, Title 55, Chapter 1101 when submitting PARP/prior authorization requests

Background and Evidence

Support surfaces (including mattress overlays, mattresses, and specialty beds) serve preventive and therapeutic purposes: preventive support surfaces are used for individuals at risk for skin breakdown and therapeutic support surfaces assist in management of advanced pressure injuries (e.g., stage 3, stage 4, or unstageable pressure injuries).

Specialty beds are designed to reduce risk of falls and entrapment and to promote safety for individuals with altered self-awareness and/or neurologic impairments; many specialty beds have design features (fewer gaps and openings) to reduce entrapment risk and often require caregiver assistance for exit.

Safety enclosures (enclosed beds or canopy systems) are intended for individuals at risk for safety in bed due to cognitive impairment or severe behavioral disorder when less intensive measures have failed; clinical evidence cited includes retrospective and randomized studies suggesting enclosure beds can be reasonable and acceptable alternatives to standard restraints in certain hospitalized patients.

The policy also references FDA and Hospital Bed Safety Workgroup guidance (for informational purposes) on dimensional and assessment guidance to reduce entrapment for hospital bed systems.

Study	Finding
Sherburne et al. 2017
Retrospective chart review (n=208) suggesting enclosure beds reasonable for certain children in acute care to ensure safety.
Nawaz et al. 2007
Single-center RCT (n=49) found SOMA Safe Enclosure comparable to standard restraints with better acceptability and no enclosure-group injuries.