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Beds and Mattresses (for Kentucky Only)
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Policy governs coverage of hospital beds, cribs, mattresses, and related accessories for UnitedHealthcare Community Plan members in Kentucky and references InterQual durable medical equipment criteria for clinical determination.
Medical Records Documentation Used for Reviews section added language specifying documentation that must support medical necessity and may be required for coverage determination.
Updated FDA section to reflect the most current information.
Coverage and Clinical Criteria
Medical necessity (general)
Covered when InterQual durable medical equipment criteria for hospital beds, cribs, accessories, or support surfaces are met.
Providers must reference the InterQual CP: Durable Medical Equipment - Hospital Beds, Cribs, and Accessories; Support Surfaces for the detailed clinical indications used to determine medical necessity.
The listing of a procedure or diagnosis code in this policy is provided for reference only. Listing of a code in this policy does not imply that the service described by the code is a covered or non‑covered health service. Benefit coverage is determined by federal, state, or contractual requirements and applicable law, and inclusion of a code does not guarantee reimbursement or claim payment.
This policy does not itself enumerate specific conditions that are considered not medically necessary. Determinations of medical necessity or non‑coverage are made by applying the referenced InterQual CP: Durable Medical Equipment clinical criteria and applicable benefit contract provisions.
Applicable Codes and Capacity Thresholds
| 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. |
| E0280 | Bed cradle, any type. |
| E0290 | Hospital bed, fixed height, without side rails, with mattress. |
What Providers Must Do
Use InterQual criteria for medical necessity determinations
Coverage decisions for hospital beds, pediatric cribs, support surfaces, and related accessories are determined using InterQual CP: Durable Medical Equipment — Hospital Beds, Cribs, and Accessories and InterQual CP: Durable Medical Equipment — Support Surfaces; providers should reference the applicable InterQual criteria when requesting prior authorization or during utilization review.
Provider-impact highlight: follow InterQual and documentation requirements
High‑impact provider note: this policy bases clinical coverage on external InterQual criteria and requires documentation availability for reviews — failure to align requests with InterQual indications or to provide required records will impede authorization and may delay or prevent coverage.
Ensure complete, legible medical record documentation
The member’s medical record must include legible documentation that fully supports the medical necessity of the requested DME; required elements include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures, and records must be made available upon request.
Denial risk for insufficient documentation
Lack of adequate, legible medical record documentation that supports the medical necessity for the requested equipment may result in denial of coverage or delays in the authorization process.
InterQual-Based Medical Necessity Logic
InterQual-based DME medical necessity
Medical necessity for durable medical equipment items referenced in this policy is determined by the external InterQual clinical criteria; summarized as:
InterQual criteria must be applied for initial and continued coverage decisions; this policy references but does not restate the detailed InterQual clinical rules.
Required Documentation for Reviews
Supply full medical records to support DME requests
Provide complete medical record documentation to support medical necessity for DME requests; documentation should include relevant medical history, physical exam findings, and results of pertinent diagnostic tests or procedures and must be legible and available upon request.
- Relevant medical history
- Physical examination findings
- Results of pertinent diagnostic tests or procedures
- Legible records maintained in the medical record and available on request
Rental, Purchase, and Related Policy References
| Equipment / Topic | Rule |
|---|---|
| General hospital beds and accessories | |
| Refer to the Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements policy for rental versus purchase guidance; this policy lists applicable HCPCS codes for billing reference but does not specify rental/purchase rules. |
Replacement Criteria for Beds, Mattresses, Accessories
Background and Scope
Hospital beds, pediatric cribs, specialized support surfaces, and related accessories are used to manage patients with mobility limitations, to prevent or treat pressure injuries, and to provide therapeutic features such as repositioning, head/foot and height adjustment, and specialized support technologies. UnitedHealthcare relies on InterQual CP: Durable Medical Equipment — Hospital Beds, Cribs, and Accessories; Support Surfaces as the clinical standard to determine medical necessity for these items; providers should reference InterQual when requesting authorization or documenting need.
Referenced Criteria and Definitions
Non-Coverage Notes
This policy does not provide an explicit list of DME items that are categorically not covered. Coverage and exclusions for specific items are determined by applying the InterQual durable medical equipment criteria and by applicable federal, state, and contractual requirements; refer to benefit documents and related DME policies for any additional coverage limitations.
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