CurrentUnitedHealthcarePolicy CS181NE.H

Beds and Mattresses (for Nebraska Only)

Medical policy governing coverage of hospital beds, pediatric cribs, mattresses, and related bed accessories for members in the state of Nebraska; aligns coverage to Nebraska DHHS DMEPOS rules and InterQual criteria where applicable.

Policy Summary

PayerUnitedHealthcare

PolicyBeds and Mattresses (for Nebraska Only)

Policy CodePolicy CS181NE.H

Change TypeRoutine review — no material changes

Effective DateMay 1, 2025

Next Review DateN/A

Key ActionDocument medical necessity per Nebraska DHHS Code 471 Chapter 7 and use InterQual criteria for pediatric cribs (E0300).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-05-01Effective date

Nebraska-onlyGeographic applicability

HCPCS listReferenced codes

CURRENTPolicy status

Coverage Criteria

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The list of procedure and diagnosis codes in this policy is provided for reference only. Listing of a code does not imply the service is covered; benefit coverage and payment are determined by federal, state, or contractual requirements and applicable laws. Other policies and guidelines may also apply and can render a service non-covered despite inclusion on the code list.

This policy does not include an internal catalog of explicit "not medically necessary" items. Instead, medical necessity determinations rely on the referenced external criteria — specifically Nebraska DHHS DMEPOS rules and, where applicable, InterQual clinical criteria. Providers must consult those external sources and applicable contractual rules to determine whether a given service is medically necessary for a member.

Referenced Codes

Referenced HCPCS codes (partial 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.

Additional referenced HCPCS codesHCPCS

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.
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.

Additional referenced HCPCS codes (continued)HCPCS

E0303	Hospital bed, heavy-duty, extra wide, weight capacity >350 lbs to <=600 lbs, with side rails, with mattress.
E0304	Hospital bed, extra heavy-duty, extra wide, weight capacity >600 lbs, with 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.
E0329	Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, includes mattress.
E0910	Trapeze bars, attached to bed, with grab bar.
E0911	Trapeze bar, heavy-duty, for patient weight capacity >250 pounds, attached to bed, with grab bar.
E1399	Durable medical equipment, miscellaneous.

Use of External Clinical Criteria

Use of state and InterQual criteria

Medical necessity determinations are made using external criteria sources:

External criteria use: Providers must apply Nebraska DHHS Code 471 Chapter 7 DMEPOS rules; InterQual CP criteria apply for pediatric cribs (E0300).

This policy does not restate the InterQual or state criteria; it directs to those sources.

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Providers: Follow InterQual criteria for pediatric cribs (HCPCS E0300). Prior authorization may be required; submit clinical documentation that demonstrates the medical necessity per InterQual and Nebraska DHHS Code 471 Chapter 7 DMEPOS criteria.

Affected code: HCPCS E0300 (Pediatric crib)
Prior authorization: per InterQual guidance
Documentation: clinical justification referencing InterQual and Nebraska DHHS Code 471 Chapter 7

Documentation Required

Provider Action

Action required: Providers should obtain prior authorization when clinically indicated and ensure submitted claims include supporting documentation tying the request to the applicable InterQual criteria and Nebraska DHHS DMEPOS rules. Verify member benefit coverage and state-specific requirements before ordering or billing.

Verify member benefits and state/federal/contractual coverage rules
Include clinical notes that map to InterQual and Nebraska DHHS Code 471 Chapter 7 criteria
Do not assume listing of a code guarantees coverage or payment

Note

Clinical Criteria Sources

Medical necessity clinical coverage criteria are determined by Nebraska DHHS Code 471 Chapter 7 for DMEPOS and by InterQual CP: Durable Medical Equipment, Hospital Beds, Cribs, and Accessories. Refer to these sources when preparing prior authorization requests and clinical documentation.

Nebraska DHHS Code 471 Chapter 7 (DMEPOS) — governs state-specific medical necessity for durable equipment
InterQual CP — used for clinical criteria and coverage determinations for hospital beds and cribs

Billing Rule

Code Listing Is Not Authorization

Inclusion of a code in this policy is for reference only and does not guarantee coverage or payment. Benefit coverage is determined by federal, state, or contractual requirements and applicable laws.

Listing a code does not imply the service is covered
Coverage and payment depend on member benefits, state law, and contract terms

Documentation Requirements

Documentation Required

Documentation: follow Nebraska DMEPOS rules and InterQual criteria

Document medical necessity per Nebraska DHHS Code 471 Chapter 7 DMEPOS rules and the applicable InterQual clinical criteria (for E0300) when ordering or supplying beds, cribs, mattresses, and accessories; include the specific clinical findings and references to the external criteria used to justify the request.

Include documentation that maps the patient’s condition to the Nebraska DMEPOS rules and/or the InterQual criteria used.
Retain copies of any prior authorization approvals and the clinical rationale cited from InterQual or state rules.

Key Definitions

inv-12: Pediatric crib, hospital grade, fully enclosed — definition mapping (E0300)

HCPCS codeE0300

Short definitionPediatric crib, hospital grade, fully enclosed (with or without top enclosure).

Clinical criteria sourceInterQual CP: Durable Medical Equipment, Hospital Beds, Cribs, and Accessories (see InterQual for medical necessity criteria).

State guidanceNebraska DHHS Code 471 Chapter 7 DMEPOS governs medical necessity determinations for pediatric cribs in Nebraska.

Coverage noteConsidered medically necessary in certain circumstances when InterQual and state DMEPOS criteria are met; inclusion in code list alone does not guarantee coverage or payment.

Rental and Purchase Rules

HCPCS code	Description
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.
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.
E0300
Pediatric crib, hospital grade, fully enclosed, with or without top enclosure.
E0301
Hospital bed, heavy-duty, extra wide, weight capacity >350 lbs to <=600 lbs, with side rails, without mattress.
E0302
Hospital bed, extra heavy-duty, extra wide, weight capacity >600 lbs, with side rails, without mattress.
E0303
Hospital bed, heavy-duty, extra wide, weight capacity >350 lbs to <=600 lbs, with side rails, with mattress.
E0304
Hospital bed, extra heavy-duty, extra wide, weight capacity >600 lbs, with 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.
E0329
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, includes mattress.
E0910
Trapeze bars, attached to bed, with grab bar.
E0911
Trapeze bar, heavy-duty, for patient weight capacity >250 pounds, attached to bed, with grab bar.
E1399
Durable medical equipment, miscellaneous.

Replacement — Beds, Mattresses, Accessories

inv-15: Beds, mattresses, accessories — Not specified in this policy

Policy statementReplacement intervals for beds, mattresses, and accessories are not specified in this policy.

Determining rulesRental vs purchase and repair/replacement rules are determined by Nebraska DHHS DMEPOS rules and related state guidance.

DocumentationMedical necessity and justification for replacements must follow Nebraska DHHS Code 471 Chapter 7 and any applicable InterQual criteria where relevant.

Coverage implicationAbsence of specified intervals in this policy means suppliers/providers must consult the related Nebraska DMEPOS policy and contractual requirements for replacement timing.

Background

This policy aligns coverage decisions for hospital beds, pediatric cribs, mattresses, and related bed accessories to external clinical rules. Medical necessity is determined by Nebraska DHHS Code 471 Chapter 7 DMEPOS rules and by InterQual CP: Durable Medical Equipment, Hospital Beds, Cribs, and Accessories for pediatric cribs (HCPCS E0300). The policy references these external sources rather than restating their detailed clinical criteria; providers must apply the state and InterQual criteria when documenting and requesting coverage.

Not Covered / Limitations

The document does not list equipment-level exclusions in this policy text. Inclusion of a HCPCS code in the policy’s reference lists does not guarantee coverage or payment; coverage may be limited or excluded by federal, state, or contractual requirements, or by other applicable policies. Providers should verify benefit coverage and any applicable exclusions with the member’s contract and follow the referenced Nebraska DMEPOS and InterQual criteria.