CurrentUnitedHealthcarePolicy CS181KS.02

Beds and Mattresses (for Kansas Only)

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Policy governing medical necessity and coverage references for beds and mattresses for UnitedHealthcare Community Plan members in Kansas; directs providers to the Kansas Medical Assistance Program DME Fee-For-Service Provider Manual for clinical criteria.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for Kansas Only)

Policy CodePolicy CS181KS.02

Change TypeDocumentation clarificationinformational FDA referencereferences updated

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionEnsure patient medical records fully document history, exam, and pertinent diagnostic results and are legible and available on request to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements to support medical necessity for requested services.

Added FDA section referencing Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

Updated References section to reflect most current information and archived previous policy version CS181KS.01.

Kansas-only

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CurrentUnitedHealthcarePolicy CS181KS.02

Beds and Mattresses (for Kansas Only)

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Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for Kansas Only)

Policy CodePolicy CS181KS.02

Change TypeDocumentation clarificationinformational FDA referencereferences updated

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionEnsure patient medical records fully document history, exam, and pertinent diagnostic results and are legible and available on request to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language clarifying medical records documentation requirements to support medical necessity for requested services.

Added FDA section referencing Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment.

Updated References section to reflect most current information and archived previous policy version CS181KS.01.

Kansas-only

Coverage Criteria

Medical necessity determination

Coverage is determined by Kansas Medical Assistance Program DME Fee-For-Service Provider Manual

State manual governs: Providers must refer to and meet the Kansas Medical Assistance Program Durable Medical Equipment Fee-For-Service Provider Manual clinical coverage criteria for beds and mattresses.

This policy does not list independent clinical criteria; it delegates to the state manual.

The HCPCS codes listed in this policy are provided for reference only. Listing of a code does not guarantee coverage or reimbursement, and inclusion of a code is not an indication that the service described by the code is a covered benefit. Benefit coverage is determined by federal, state, contractual requirements, and applicable law; other policies and guidelines may also affect coverage and payment.

This policy does not itself enumerate specific conditions or scenarios that are considered not medically necessary. Determinations about medical necessity, including whether an item is not medically necessary, are made according to the clinical coverage criteria in the applicable state program and related manuals rather than by this policy text.

Applicable HCPCS and Coding Details

Applicable HCPCS (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

Applicable HCPCS (part 2)HCPCS

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
E0277	Powered pressure-reducing air mattress
E0280	Bed cradle, any type
E0290	Hospital bed, fixed height, without side rails, with mattress
E0291	Hospital bed, fixed height, without side rails, without mattress

1–10 of 16

1/2

Applicable HCPCS (part 3)HCPCS

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
E0303	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, with mattress
E0304	Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress
E0305	Bedside rails, half-length
E0310	Bedside rails, full-length
E0316	Safety enclosure frame/canopy for use with hospital bed, any type
E0328	Hospital bed, pediatric, manual, 360-degree side enclosures, includes mattress
E0911	Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

Bariatric weight capacity (codes)

Bariatric code groupingsCodes differentiate bariatric bed capacity into >350 lb and >600 lb categories (E0301/E0303 = >350 lb up to 600 lb; E0302/E0304 = >600 lb).

E0301 / E0303Hospital bed, heavy‑duty, extra wide, weight capacity greater than 350 pounds but less than or equal to 600 pounds (E0301 without mattress; E0303 with mattress).

E0302 / E0304Hospital bed, extra heavy‑duty, extra wide, weight capacity greater than 600 pounds (E0302 without mattress; E0304 with mattress).

Trapeze bar capacity noteE0911 specifies trapeze bar, heavy‑duty, for patient weight capacity greater than 250 pounds — relevant for bariatric support accessories.

Provider Actions and Billing

Prior Authorization

Prior authorization / coding reference — follow Kansas DME manual

Coverage and billing for the HCPCS bed and mattress codes listed in this policy are subject to the Kansas Medical Assistance Program Durable Medical Equipment Fee‑For‑Service Provider Manual clinical criteria and applicable benefit terms; providers must verify and meet the state DME manual authorization requirements prior to billing.

Applies to the HCPCS codes listed in the policy (see Coding section).
Providers should verify authorization requirements per the Kansas DME manual before submitting claims.

Note

Provider actions — verify state criteria and include code-specific info

Providers must submit complete, legible medical record documentation that supports medical necessity for requested beds and mattresses and follow state manual requirements; consult the Kansas DME manual and this policy's coding lists when preparing requests.

Reference the specific HCPCS codes in the policy when requesting authorization.

Background

Clinical medical necessity criteria for beds and mattresses are delegated to the Kansas Medical Assistance Program Durable Medical Equipment Fee-For-Service Provider Manual. Providers must refer to and meet the state DME manual’s clinical coverage criteria when requesting authorization or submitting claims for bed and mattress items.

Definitions and HCPCS Categories

Beds and mattresses HCPCS categories

Hospital bed categoriesMultiple hospital bed types are listed: fixed height, variable height (hi‑lo), semi‑electric, total electric, pediatric, heavy‑duty/extra wide (bariatric).

Therapeutic mattressesPowered air flotation beds (E0193), air fluidized beds (E0194), and powered pressure‑reducing air mattresses (E0277) are included.

Accessories and safety devicesBed cradles (E0280), bedside rails (E0305/E0310), safety enclosure frames/canopies (E0316), and trapeze bars (E0911) are listed as accessories.

Pediatric beds/cribsPediatric hospital cribs and pediatric hospital beds with 360‑degree side enclosures are included (E0300, E0328).

Medical Necessity — State Criteria

State manual criteria

Refer to Kansas Medical Assistance Program DME Fee-For-Service Provider Manual for medical necessity criteria

State-defined criteria: Medical necessity and coverage criteria are as specified in the Kansas DME manual; providers must meet those requirements.

No local criteria listed in this policy.

Rental and Purchase Rules

Equipment	Rental vs Purchase Rule
All listed bed and mattress HCPCS (see Coding section)
Refer to the Kansas Medical Assistance Program Durable Medical Equipment Fee-For-Service Provider Manual for rental versus purchase determination for all listed bed and mattress HCPCS.

Replacement Rules

Beds and mattresses replacement

Replacement interval sourceReplacement intervals for beds and mattresses are governed by the Kansas Medical Assistance Program Durable Medical Equipment Fee‑For‑Service Provider Manual (state manual).

Policy delegationThis UnitedHealthcare policy defers to the Kansas DME manual for specifics on replacement timing and eligibility; no local intervals are specified here.

Provider action implicationProviders must follow the state manual’s replacement rules when requesting replacement beds or mattresses for Kansas members.

Documentation Requirements

Documentation Required

Required — documentation must fully support medical necessity and be available on request

Medical record documentation must fully support medical necessity — including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures — and be legible, maintained in the record, and made available upon request.

Documentation should explicitly tie clinical findings to the specific bed or mattress HCPCS code requested.
Retain all supporting records and produce them if requested during review.

Not Covered / Limitations

There are no express local exclusions listed in this policy beyond the general statement that inclusion of a code does not imply coverage. Coverage of the listed HCPCS codes is contingent on meeting the Kansas DME manual criteria, applicable benefit terms, and contractual requirements; some listed codes may not be covered in specific circumstances.