UnitedHealthcare Beds and Mattresses Coverage Update

Coverage Criteria

inv-01: Safety Enclosure Coverage Criteria

Safety enclosure with beds are covered when ALL of the following are met:

Safety enclosure coverage: Use of equipment is required due to a diagnosis related to cognitive impairment (for example: traumatic brain injury, cerebral palsy, seizure disorder) or a severe behavioral disorder.

Medication optimization: Medications to address seizures and/or disruptive or harmful behaviors have been optimized or are not appropriate.

Documented safety risk: There is a safety risk that includes but is not limited to: claustrophobia; high risk of falls due to a clinical condition; uncontrolled movements; violent or self-destructive behaviors such as uncontrolled head banging.

Trial of less intensive alternatives: Less intensive alternative methods have been tried as appropriate and have not been successful or are contraindicated. Examples: mattress placed on the floor; medical helmet; removal of all safety hazards; side rails; weighted blankets.

Safety enclosure with beds should be coded with HCPCS E0316.

The listing of HCPCS and other procedure codes in this policy is provided for reference only and does not by itself indicate that a service is covered. Benefit coverage for any service is determined by the member’s specific benefit plan document and by applicable law. Inclusion of a code in this guideline does not guarantee reimbursement or claim payment, and other policies or guidelines may apply.

No individual items are explicitly identified as "not medically necessary" in this policy beyond the general caveat regarding coding and coverage. The presence of a HCPCS code in the list does not imply the service is covered, and a specific service may be deemed noncovered or not medically necessary based on the member’s benefit plan or applicable law.

Coding and HCPCS

Applicable 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.

1–10 of 21

1/3

Applicable HCPCS Codes (part 2)HCPCS

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, 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.

1–10 of 11

1/2

inv-06: Heavy-duty bed weight capacity thresholds

>350 to ≤600 lb capacityHeavy‑duty extra wide hospital bed models with weight capacity greater than 350 pounds but less than or equal to 600 pounds (HCPCS E0301, E0303).

>600 lb capacityExtra heavy‑duty extra wide hospital bed models with weight capacity greater than 600 pounds (HCPCS E0302, E0304).

Coding noteUse the specific HCPCS code that matches both capacity and mattress inclusion (codes differentiate with/without mattress).

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior authorization or medical necessity review is required per InterQual® CP criteria for support surfaces and hospital beds. Medical necessity determinations reference the InterQual CP: Durable Medical Equipment — Support Surfaces and Hospital Beds, Cribs, and Accessories criteria and require supporting clinical documentation at the time of prior authorization.

InterQual CP criteria required for review
Submit clinical documentation to support medical necessity

Step Therapy

Step Therapy Required for Safety Enclosures

Safety enclosures (e.g., pediatric enclosed bed, adult safety enclosure; HCPCS E0316) are subject to step therapy: less intensive alternatives must be tried and documented as unsuccessful or contraindicated prior to authorization of a safety enclosure.

Affected code: HCPCS E0316
Required trialed alternatives include mattress on floor, medical helmet, removal of hazards, side rails, weighted blankets

Medical Necessity Criteria

inv-15: Safety enclosures (DME) medical necessity

Covered when ALL of the following are met:

Clinical indication: Diagnosis related to cognitive impairment (e.g., traumatic brain injury, cerebral palsy, seizure disorder) or a severe behavioral disorder necessitating use of a safety enclosure.

Medication consideration: Medications to address seizures and/or disruptive or harmful behaviors have been optimized or are inappropriate for the member.

Specific safety risks documented: Documented safety risk including one or more of: claustrophobia; high risk of falls due to a clinical condition; uncontrolled movements; violent or self-destructive behaviors (for example, uncontrolled head banging).

Prior trial of alternatives:

Required Documentation

Documentation Required

Clinical documentation required to support safety enclosure requests

Document the cognitive or behavioral diagnosis, medication optimization or rationale if medications are not appropriate, a clear description of the safety risk (for example falls risk, uncontrolled movements, violent or self‑destructive behaviors, or claustrophobia), and evidence of trial and failure or contraindication of less intensive alternatives when requesting a safety enclosure.

Diagnosis related to cognitive impairment or severe behavioral disorder
Evidence medications were optimized or reason they are not appropriate
Description of the safety risk (falls risk, uncontrolled movements, violent/self‑destructive behaviors, claustrophobia)
Documentation of trial and failure or contraindication of less intensive alternatives

Definitions

inv-12: Support surfaces

DefinitionMattress overlays, mattresses, and specialty beds used for prevention or treatment of skin breakdown and pressure injuries.

Preventive vs therapeuticPreventive support surfaces are used for individuals at risk for skin breakdown; therapeutic surfaces assist with advanced pressure injuries (stage 3, 4, or unstageable).

Product examplesIncludes mattress overlays applied on top of a mattress, pressure‑reducing mattresses, and specialty beds designed to reduce pressure injury risk.

inv-13: Specialty beds

DefinitionBeds designed to keep individuals with altered self‑awareness and/or neurologic impairments from falling out of bed or suffering injury.

Design featuresMay have fewer gaps and openings to reduce entrapment risk and often require caregiver assistance to exit.

Rental, Purchase and Replacement

HCPCS code	Description / coverage note
E0193
Powered air flotation bed (low air loss therapy) — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0194
Air fluidized bed — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0250
Hospital bed, fixed height, with any type side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0251
Hospital bed, fixed height, with any type side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0255
Hospital bed, variable height, hi-lo, with any type side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0256
Hospital bed, variable height, hi-lo, with any type side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0260
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0261
Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0265
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0266
Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0277
Powered pressure-reducing air mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0280
Bed cradle, any type — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0290
Hospital bed, fixed height, without side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0291
Hospital bed, fixed height, without side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0292
Hospital bed, variable height, hi-lo, without side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0293
Hospital bed, variable height, hi-lo, without side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0294
Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0295
Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0296
Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0297
Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0300
Pediatric crib, hospital grade, fully enclosed, with or without top enclosure — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0301
Hospital bed, heavy-duty, extra wide, capacity >350 lb to ≤600 lb, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0302
Hospital bed, extra heavy-duty, extra wide, capacity >600 lb, without mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0303
Hospital bed, heavy-duty, extra wide, capacity >350 lb to ≤600 lb, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0304
Hospital bed, extra heavy-duty, extra wide, capacity >600 lb, with mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0305
Bedside rails, half-length — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0310
Bedside rails, full-length — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0316
Safety enclosure frame/canopy for use with hospital bed, any type — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0328
Hospital bed, pediatric, manual, 360-degree side enclosures, includes mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0329
Hospital bed, pediatric, electric or semi-electric, 360-degree side enclosures, includes mattress — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0910
Trapeze bars (Patient Helper), attached to bed, with grab bar — listing for reference; coverage determined by member-specific benefit plan and applicable law.
E0911
Trapeze bar, heavy-duty, for patient weight capacity >250 lb, attached to bed, with grab bar — listing for reference; coverage determined by member-specific benefit plan and applicable law.

inv-17: Replacement rules

Replacement guidance statusNo specific replacement intervals or rules are provided in this policy document; replacement guidance is not specified.

Billing implicationHCPCS code listings are for reference only and do not imply coverage or replacement entitlement; coverage and replacement are determined by the member’s benefit plan and applicable law.

Documentation tie‑inAny replacement request should include clinical documentation supporting medical necessity per InterQual criteria and plan requirements (when applicable).

Not Covered

This policy does not provide a discrete list of DME items that are categorically non‑covered. Coverage determinations are subject to the member’s benefit plan and applicable legal requirements; therefore, absence of an explicit non‑covered list here does not preclude that certain items or services may be noncovered under an individual member’s plan.

Background

Support surfaces include products ranging from simple mattress overlays to full specialty beds and are used to prevent and treat pressure injuries and skin breakdown. Specialty beds provide additional functionality beyond a standard bed — for example, features that reduce gaps and entrapment risk, aid caregivers in assisting patients to exit the bed, and protect individuals with altered awareness or neurologic impairment from falls or injury. Enclosed or safety‑enclosure beds incorporate frames or canopies when an individual poses a safety risk in bed related to cognitive impairment or severe behavioral disorders.

Revision History

2025-05-01revisionLatest

Updated FDA section to reflect the most current information and archived previous policy version CS181NM.A.

OpenPayer

Beds and Mattresses (for New Mexico Only)