CurrentUnitedHealthcarePolicy CS181KS.01

Beds and Mattresses (for Kansas Only)

This policy governs clinical coverage references and applicable billing codes for beds and mattresses for UnitedHealthcare members in Kansas; it directs readers to the Kansas Medical Assistance Program DME Fee-for-Service Provider Manual for medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for Kansas Only)

Policy CodePolicy CS181KS.01

Change TypeNew Medical Policy

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionRefer to the Kansas Medical Assistance Program DME Fee-for-Service Provider Manual for medical necessity criteria and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

New Medical Policy

>=40HCPCS codes listed for beds/mattresses and related items

KansasGeographic applicability

1New policy entries

Coverage and Medical Necessity

Medical necessity determination

Coverage and medical necessity determinations follow the Kansas Medical Assistance Program DME Fee-for-Service Provider Manual.

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Primary rule: Medical necessity for beds and mattresses is determined by the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual.

Refer to the Kansas DME Fee-for-Service Provider Manual for specific clinical criteria, documentation, and authorization requirements.

The codes listed in this policy are provided for reference only. Listing a code does not imply that the service described by the code is a covered service, nor does it guarantee reimbursement. Benefit coverage is determined by federal, state, or contractual requirements and applicable law, and other policies or guidelines may apply.

This document does not identify any specific items as not medically necessary. Coverage and medical necessity determinations defer to the governing benefit rules and the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Provider Manual.

Referenced HCPCS Codes and Definitions

Referenced HCPCS Codes (part 1)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.

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Referenced HCPCS Codes (part 2)HCPCS

E0291	Hospital bed, fixed height, without side rails, without mattress.
E0292	Hospital bed, variable height, hi-lo, without side rails, with mattress.
E0293	Hospital bed, variable height, hi-lo, without side rails, without mattress.
E0294	Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress.
E0295	Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress.
E0296	Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress.
E0297	Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress.
E0300	Pediatric crib, hospital grade, fully enclosed, with or without top enclosure.
E0301	Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress.
E0302	Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress.

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Referenced HCPCS Codes (part 3)HCPCS

E0328	Hospital bed, pediatric, manual, 360-degree side enclosures, top of headboard, footboard, and side rails up to 24 in above the spring, includes mattress.
E0329	Hospital bed, pediatric, electric or semi-electric, 360-degree side enclosures, top of headboard, footboard, and side rails up to 24 in above the spring, includes mattress.
E0910	Trapeze bars, also known as Patient Helper, attached to bed, with grab bar.
E0911	Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar.
E1399	Durable medical equipment, miscellaneous.

Wheelchair/bed weight capacity threshold — definitions

Heavy-duty thresholdDefined as weight capacity greater than 350 pounds (i.e., >350 lbs)

Extra heavy-duty thresholdDefined as weight capacity greater than 600 pounds (i.e., >600 lbs)

Policy applicationWeight-capacity designations are used to distinguish E0301–E0304 hospital bed codes for coverage and coding purposes

E0193 — definition

HCPCS codeE0193

TermPowered air flotation bed (low air loss therapy)

ContextListed in Applicable Codes as a referenced HCPCS code for beds and mattresses

E0301–E0304 — hospital bed definitions

E0301Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress

E0302Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress

E0303Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress

E0304Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress

Provider Responsibilities and Guidance

Note

Refer to Kansas DME Manual

For medical necessity clinical coverage criteria for beds and mattresses, refer to the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Provider Manual.

Note

Code listing is informational

Listing of procedure and diagnosis codes in this policy is informational and does not guarantee coverage or payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Example codes listed in source for reference only: E0193, E0194, E0250–E0256, E0260–E0266, E0265, E0277, E0280, E0290.

Prior Authorization

Check governing benefit requirements

Check the governing benefit plan, state or federal requirements, and the member’s contract prior to rendering services; in the event of a conflict, the federal, state, or contractual requirements govern.

Documentation Required

Provider-facing guidance

This Medical Policy is informational and does not substitute for professional medical judgment. UnitedHealthcare may modify policies and uses InterQual® (and ASAM for SUD) for clinical criteria; if InterQual® is not applicable, UnitedHealthcare policies approved by the Kansas Department of Health and Environment may be used.

Where to Find Medical Necessity Criteria

Refer to Kansas DME Manual

Medical necessity clinical coverage criteria are not specified in this policy and are provided by the Kansas DME manual.

Referential criteria: Use the Kansas Medical Assistance Program Durable Medical Equipment Fee-for-Service Provider Manual for detailed medical necessity criteria for DME beds and mattresses.

Providers must follow the Kansas DME manual for prior authorization, required documentation, and any state-specific benefit rules that govern coverage.

Rental vs Purchase Guidance

Item	Policy guidance
Beds and mattresses	This policy does not specify rules for rental versus purchase of beds and mattresses. Providers should consult the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Provider Manual and the member's applicable federal, state, or contractual benefit plan to determine rental vs. purchase coverage and any authorization requirements; in the event of a conflict, federal, state, or contractual requirements govern.

Item

Policy guidance

Beds and mattresses

This policy does not specify rules for rental versus purchase of beds and mattresses. Providers should consult the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Provider Manual and the member's applicable federal, state, or contractual benefit plan to determine rental vs. purchase coverage and any authorization requirements; in the event of a conflict, federal, state, or contractual requirements govern.

Replacement Rules for Beds and Mattresses

Beds and mattresses — replacement / inventory note

Inventory entry presentBeds and mattresses — inventory entry exists but details are managed via the Kansas Medical Assistance Program DME Fee-for-Service Provider Manual

Replacement detailsNo specific replacement intervals are specified in this policy; providers should consult the Kansas DME Manual and applicable benefit contracts

Action for providersRefer to governing federal, state, or contractual benefit requirements for replacement and authorization rules

Documentation and Prior Authorization

Documentation Required

Follow Kansas DME Manual and applicable benefit documentation rules

Follow the Kansas Medical Assistance Program DME Fee-for-Service Provider Manual for required documentation, prior authorization procedures, and medical necessity documentation; also confirm any additional federal, state, or contractual documentation requirements.

Use the Kansas DME manual as the primary source for authorization documentation requirements.
Confirm and comply with federal/state/contractual documentation rules that may apply to the member's benefit.

Policy Background

This policy does not itself establish clinical medical necessity criteria for beds and mattresses. Providers should use the Kansas Medical Assistance Program Durable Medical Equipment Fee‑for‑Service Provider Manual to determine medical necessity and authorization requirements for these items.

Not Covered Items

No specific beds, mattresses, or related items are declared explicitly not covered in this policy. The HCPCS code listing is informational only; actual coverage is determined by the Kansas DME Manual, federal/state/contractual benefit requirements, and any other applicable policies.

Key Definitions

Definition — E0193 (powered air flotation bed)

CodeE0193

DefinitionPowered air flotation bed (low air loss therapy)

Source noteListed under 'Applicable Codes' in the policy; inclusion is informational and does not guarantee coverage

Definitions — E0301–E0304 (heavy-duty / extra heavy-duty hospital beds)

E0301 / E0303Heavy-duty, extra wide — weight capacity >350 lbs and ≤600 lbs (E0301 without mattress; E0303 with mattress)

E0302 / E0304Extra heavy-duty, extra wide — weight capacity >600 lbs (E0302 without mattress; E0304 with mattress)

UsageCodes distinguish heavy vs extra heavy capacity and whether a mattress is included; used for coding hospital beds in the policy

Policy Changes

2025-06-01policy_createdLatest

New medical policy created and entered into the revision history effective 06/01/2025.