CurrentUnitedHealthcarePolicy CSNC.MP.100.08

Beds and Mattresses (for North Carolina Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CSNC.MP.100.08 alerts

Get alerted when Policy CSNC.MP.100.08 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines UnitedHealthcare Community Plan coverage guidance for beds and mattresses (durable medical equipment) applicable to North Carolina Medicaid members, referencing the NC Medicaid Clinical Coverage Policy for clinical criteria.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for North Carolina Only)

Policy CodePolicy CSNC.MP.100.08

Change TypeOperational and informational updates

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the North Carolina Medicaid Clinical Coverage Policy 5A-1 prior authorization process and ensure medical records fully document medical necessity and are available upon request.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: Added language clarifying documentation requirements to support medical necessity and that documentation may be required but does not guarantee coverage.

Updated FDA section to reflect the most current information.

North Carolina

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentUnitedHealthcarePolicy CSNC.MP.100.08

Beds and Mattresses (for North Carolina Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CSNC.MP.100.08 alerts

Get alerted when Policy CSNC.MP.100.08 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for North Carolina Only)

Policy CodePolicy CSNC.MP.100.08

Change TypeOperational and informational updates

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionFollow the North Carolina Medicaid Clinical Coverage Policy 5A-1 prior authorization process and ensure medical records fully document medical necessity and are available upon request.

SourceLink

POLICY UPDATE CHANGES

Updated FDA section to reflect the most current information.

North Carolina

Coverage Criteria

Medical necessity (delegated to NC Medicaid 5A-1)

Covered when ALL of the following are met per North Carolina Medicaid Clinical Coverage Policy 5A-1

NC Medicaid 5A-1 governs clinical coverage: Medical necessity clinical coverage criteria are those in the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Medical Equipment, 5A-1: Physical Rehabilitation Equipment and Supplies.

Providers must refer to that document for specific indications, repair and replacement criteria.

Codes marked with an asterisk (*) in the HCPCS lists are not included on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program. Providers should verify coverage and applicable billing rules with the NC Medicaid Fee Schedule before submitting claims for asterisked codes.

Listing a HCPCS code in this policy is for reference only and does not imply coverage, guarantee reimbursement, or guarantee claim payment. Benefit coverage is determined by federal, state, contractual requirements, and applicable laws; other policies or guidelines (including prior authorization requirements) may apply.

Coding and Codes

Referenced HCPCS 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.

1–10 of 29

1/3

Weight capacity thresholds

>350 lbs to <=600 lbsHeavy-duty, extra wide hospital beds with weight capacity greater than 350 pounds but less than or equal to 600 pounds (HCPCS: E0301, E0303)

>600 lbsExtra heavy-duty, extra wide hospital beds with weight capacity greater than 600 pounds (HCPCS: E0302, E0304)

Related requirementCodes marked with an asterisk may not be on the NC Medicaid Fee Schedule and therefore may not be covered by NC Medicaid.

HCPCS equipment descriptions

E0193Powered air flotation bed (low air loss therapy)

E0194Air fluidized bed

E0277Powered pressure-reducing air mattress

E0300Pediatric crib, hospital grade, fully enclosed, with or without top enclosure

E0301 / E0303Hospital bed, heavy-duty, extra wide, weight >350 lbs to <=600 lbs (E0301 without mattress; E0303 with mattress)

E0302 / E0304Hospital bed, extra heavy-duty, extra wide, weight >600 lbs (E0302 without mattress; E0304 with mattress)

Provider Actions & Requirements

Prior Authorization

Follow NC Medicaid 5A-1 prior authorization

Coverage for beds and mattresses follows the North Carolina Medicaid Clinical Coverage Policy, Medical Equipment 5A-1; providers must follow that policy's prior authorization process where applicable.

Note

Operational: documentation & coverage determination

Operational note: follow state policy and make documentation available upon request; benefit determination is subject to federal, state, and contractual requirements.

Benefit coverage is determined by federal, state, or contractual requirements and applicable laws.
Documentation may be required to assess whether the member meets clinical criteria but does not guarantee coverage.

Medical Necessity (Delegated Rules)

DME medical necessity (delegated)

Medical necessity criteria and repair/replacement rules are those specified in NC Medicaid Clinical Coverage Policy 5A-1; this policy defers to that document for clinical decision logic.

Refer to NC Medicaid 5A-1: All clinical indications, contraindications, and repair/replacement criteria are defined in the referenced NC Medicaid policy.

This policy contains no independent clinical thresholds; providers must follow the NC Medicaid 5A-1 policy for prior authorization, repair and replacement intervals.

Rental, Purchase, Repair & Replacement

Rule	Guidance / Source
Rental vs. purchase determination	Determinations regarding rental versus purchase of beds and mattresses are governed by the North Carolina Medicaid Clinical Coverage Policy, Medical Equipment, 5A-1: Physical Rehabilitation Equipment and Supplies; providers must follow the criteria and procurement rules specified in that NC Medicaid policy.
Repair and replacement rules	Repair, replacement, and interval criteria for beds and mattresses defer to the North Carolina Medicaid Clinical Coverage Policy 5A-1; refer to that policy for specific replacement intervals and allowable repairs or replacements.
Prior authorization and documentation	Follow the prior authorization process and documentation requirements as specified by NC Medicaid 5A-1; medical records must support medical necessity and be made available upon request.

Beds and mattresses — replacement guidance

Replacement rules sourceRepair and replacement intervals and criteria for beds and mattresses are governed by the North Carolina Medicaid Clinical Coverage Policy 5A-1; refer to that policy for specific intervals and clinical criteria.

Rental vs purchasePolicy defers to NC Medicaid Clinical Coverage Policy 5A-1 for rental versus purchase determinations and related rules.

Documentation for replacementsMedical record must fully support medical necessity and include relevant history, physical exam, and diagnostic test results; records must be made available upon request.

ScopeThis policy addresses beds and mattresses (DME) for North Carolina Medicaid members and defers clinical decision logic to NC Medicaid 5A-1.

Documentation Requirements

Documentation Required

Document medical necessity and provide records for review

Document medical necessity clearly in the patient record and ensure those records are maintained and made available for review upon request.

Include relevant medical history, physical exam findings, and results of pertinent diagnostic tests or procedures.
Keep documentation legible and accessible for review.

Not Covered

HCPCS codes in this policy that are marked with an asterisk (*) are not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the NC Medicaid Program. Providers should confirm coverage with NC Medicaid and follow any applicable prior authorization or billing procedures before furnishing services for these codes.

Background

This policy provides UnitedHealthcare Community Plan guidance for durable medical equipment beds and mattresses for members in North Carolina and defers to the North Carolina Medicaid Clinical Coverage Policy 5A-1 (Medical Equipment) for clinical indications, medical necessity determinations, and repair/replacement rules. It also notes FDA guidance on hospital bed entrapment and dimensional assessment for informational purposes. Providers must follow the NC Medicaid policy for prior authorization and clinical criteria when requesting beds, mattresses, and related accessories.