CurrentUnitedHealthcarePolicy CS181.H

Beds, Specialty Beds, Safety Enclosures (Enclosure Beds) and Support Surfaces (Mattresses/Overlays)

UnitedHealthcare medical policy CS181.H covers hospital beds, specialty beds, safety enclosures (enclosure beds) and support surfaces (mattresses/overlays) as durable medical equipment (DME) with clinical necessity criteria; excludes certain state-specific applicability. References InterQual CP: Durable Medical Equipment criteria for detailed medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicyBeds, Specialty Beds, Safety Enclosures (Enclosure Beds) and Support Surfaces (Mattresses/Overlays)

Policy CodePolicy CS181.H

Change TypeApplication update; template updates

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionDocument clinical necessity and prior trials: providers should document diagnosis, medication optimization or contraindication, specific safety risks, and attempts at less intensive alternatives to support coverage.

POLICY UPDATE CHANGES

06/01/2025 Application updated to indicate the policy does not apply to Idaho and Kansas and updated reference link to Medical Records Documentation Used for Reviews.

05/01/2025 Replaced list of Required Clinical Information with instruction to refer to the protocol titled Medical Records Documentation Used for Reviews; updated FDA section and archived previous policy version CS181.G.

07/01/2025 Template Update removed content/language pertaining to the state of Mississippi.

04/01/2026 Template Update removed content/language pertaining to the state of Louisiana.

1Primary coverage condition group (safety enclosure criteria sets)

yesInterQual referenced

Coverage Summary

Policy CS181.H (effective May 1, 2025, last reviewed April 1, 2026) addresses coverage of safety enclosures, hospital and specialty beds, and support surfaces (mattresses/overlays) as durable medical equipment when clinical necessity criteria are met. UnitedHealthcare references InterQual CP: Durable Medical Equipment for detailed medical necessity guidance and notes that the policy excludes certain state-specific applicability.

Quick policy key-values

Policy numberCS181.H

Effective dateMay 1, 2025

Last reviewApril 1, 2026

StatusCURRENT

SubjectSafety enclosures, beds, and mattresses (DME)

Scope summaryCovers hospital beds, specialty beds, safety enclosures (enclosure beds) and support surfaces (mattresses/overlays) as DME with clinical necessity criteria; excludes certain state-specific applicability and references InterQual CP for detailed medical necessity.

Medical Necessity Criteria

Safety enclosure with beds (coverage criteria)

Covered as DME when ALL of the following criteria are met:

ALL of the following

Use of equipment is required due to a diagnosis related to cognitive impairment (e.g., traumatic brain injury, cerebral palsy, seizure disorder) or a severe behavioral disorder
Medications to address seizures and/or disruptive or harmful behaviors have been optimized or are not appropriate
ALL of the following
- ONE of
  - Claustrophobia

Provider Actions & Billing Notes

Documentation Required

Document clinical necessity and prior trials

Medical records documentation may be required to assess whether the member meets clinical criteria; providers should document diagnosis (cognitive impairment or severe behavioral disorder), optimization or contraindication of medications, specific safety risks, and attempts at less intensive alternatives.

Diagnosis: cognitive impairment or severe behavioral disorder
Documentation that medications to address seizures/disruptive behaviors have been optimized or are contraindicated
Specific safety risks (e.g., high fall risk, uncontrolled movements, violent or self-destructive behaviors)
Attempts at less intensive alternatives and outcomes (e.g., mattress on floor, medical helmet, removal of hazards, side rails, weighted blankets)

Billing Rule

Relevant Codes

Relevant HCPCS codes (reference list)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.

Background & Evidence

Support surfaces (mattresses and mattress overlays) may be used preventively or therapeutically for pressure injury management; therapeutic surfaces are used for advanced pressure injuries (stage 3, stage 4, or unstageable).

Specialty beds are designed to reduce fall and entrapment risk for individuals with altered self-awareness or neurologic impairments, promote safety while asleep and awake, often have reduced gaps/openings to lower entrapment risk, and frequently require caregiver assistance to exit.

Safety enclosures (enclosure beds) are intended to reduce fall and entrapment risk and ensure safety for individuals at risk in bed; evidence cited includes observational studies (e.g., retrospective pediatric enclosure bed review) and a small randomized trial comparing safety enclosures to standard restraints.

The policy’s application excludes certain states (for example, Idaho and Kansas are explicitly excluded and have state-specific policies); recent template updates removed content for other states per policy history.

Citation	Study summary
Sherburne et al. 2017	Exploratory retrospective chart review of 208 pediatric enclosure bed encounters; authors concluded enclosure beds are a reasonable intervention for certain children to ensure safety in the hospital setting.
Nawaz et al. 2007	Single-center randomized controlled trial (n=49) comparing SOMA Safe Enclosure vs standard restraints; no difference in agitation, length of stay, time in restraints, or medication doses; enclosure judged more acceptable and had no injuries vs one injury in restraints group.
ECRI 2019	Report (clinical utility assessment) describing specialty beds for children with special needs, noting they promote safety and may require caregiver assistance to exit.

Support surfaces: Mattress overlays applied on top of a mattress, mattresses, and specialty beds that can be preventive or therapeutic for skin breakdown.

Specialty beds: Beds designed to prevent falls or injury in individuals with altered self-awareness or neurologic impairments, often requiring caregiver assistance to exit.

Revision History

04/01/2026revised

Template Update removed content/language pertaining to the state of Louisiana.

07/01/2025revised

Template Update removed content/language pertaining to the state of Mississippi.

06/01/2025revisedLatest

Application updated to indicate the policy does not apply to Idaho and Kansas and updated reference link to Medical Records Documentation Used for Reviews.