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Pressure-Reducing Support Surfaces

Policy Number: MP-247

Latest Review Date: December 2020

Category: Durable Medical Equipment

Policy Grade: Active Policy but no longer scheduled for regular literature reviews and updates.

POLICY:

Group 1 - Mattress overlays and mattresses (E0180-E0187, E0196-E0199, E0371-E0373, A4640)

A Group 1 mattress overlay or mattress may be considered medically necessary when the following criteria are met:

  1. The mattress overlay or mattress is one on which the patient does not "bottom out" (see Key Points); and
  2. The patient is limited in mobility, usually requiring the assistance of another individual for positional changes

OR

  1. Any stage pressure ulcer on the trunk or pelvis; or
  2. Impaired nutritional status; and at least one of the following:
    1. Fecal or urinary incontinence; or
    2. Altered sensory perception; or
    3. Compromised circulatory status.

Foam overlay or mattress without waterproof covers is considered not medically necessary, as they are not considered durable equipment.

Group 2 - Special Mattresses alone or fully integrated into a bed (E0193, E0277, E0371-E0373)

A Group 2 support surface may be considered medically necessary when the following criteria are met:

1.   The Group 2 support surface is one on which the patient does not "bottom out" (see Key Points); and

2.   Multiple stage II pressure ulcers located on the trunk or pelvis; and

3.   Patient has been on a comprehensive ulcer treatment program for at least one month, which has included the use of an appropriate Group 1 support surface; and  

4.   The ulcers have worsened or remained the same over the past month.

OR

  1. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis.

OR

  1. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days); and
  2. The patient has been on a Group 2 or 3 support surfaces immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

OR

  1. Protein calorie malnutrition requiring parenteral or enteral supplements; and
    1. The mattress overlay or mattress is one on which the patient does not "bottom out" (see Key Points); and
    2. The patient is limited in mobility, usually requiring the assistance of another individual for positional changes

When a Group 2 device is used as part of a treatment plan for wound healing, the device may be considered medically necessary until:

  1. The ulcer is healed; or
  2. If healing does not continue, there is documentation in the medical record to show that:
    1. Other aspects of the care plan are being modified to promote healing; or
    2. The use of the Group 2 support surface is medically necessary for wound management.

Group 3 – Air-Fluidized Beds (E0194)  

An air-fluidized bed may be considered medically necessary in the treatment of post myocutaneous flap procedures in the bedridden or wheelchair bound patient with severely limited mobility or extensively burned individual when all of the following criteria are met:

  1. Recent myocutaneous flap or skin graft for a stage III or IV pressure ulcer or extensive burn on the trunk or pelvis (surgery within the past 30 days); and
  2. The plan of care is outlined for transition to Group 2 support system after this time; and
  3. A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air fluidized bed system and its problems, such as leakage; and
  4. A physician directs the home treatment regimen and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; and
  5. Anticipated surgery date is included with the request, if applicable; and
  6. The home environment is able to support the structural needs of the equipment (weight of bed >1,600 pounds) and the electrical system is sufficient to accommodate the anticipated increase in energy consumption even in the event of a power outage.

Initial certification of E0194 is for 8 weeks, continued recertification requires submission of clinical documentation verifying medical necessity.

DESCRIPTION OF PROCEDURE OR SERVICE:

Pressure-reducing support surfaces include mattress overlays, special mattresses that can be separately purchased or whole beds. Pressure-reducing support surfaces are designed for patients with limited or no mobility who are bed confined most or all of the day and therefore prone to developing pressure ulcers over bony prominences.

Pressure reducing support surfaces are a type of durable medical equipment (DME) used for the care of pressure sores, also known as pressure ulcers. Pressure ulcers are lesions caused by unrelieved pressure resulting in damage of underlying tissue. A major distinction between support surfaces is that some are powered by electricity and others are not. They may be categorized into the following three groups:

  • Group 1 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include mattresses, pressure pads and mattress overlays (foam, air, water, or gel).
  • Group 2 support surfaces are generally designed to either replace a standard hospital or home mattress or as an overlay placed on top of a standard hospital or home mattress. Products in this category include powered air flotation beds, powered pressure reducing air mattresses, and non-powered advanced pressure reducing mattresses.
  • Group 3 support surfaces are complete bed systems, known as air-fluidized beds, which use the circulation of filtered air through silicone beads.

Group 1 - Mattress Overlays and Mattresses
HCPCS codes E0185, E0197-E0199, and E0371 describe non-powered pressure-reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress.

A gel mattress overlay (E0185) is characterized by a gel layer with a height of two inches or greater.

An air mattress overlay (E0197), is characterized by interconnected air cells having a cell height of three inches or greater that are inflated with an air pump.

A water mattress overlay (E0198) is characterized by a filled height of three inches or greater.

A foam mattress overlay (E0199) is characterized by all of the following:

  • Base thickness of two inches or greater and peak height of three inches or greater if it is a convoluted overlay (e.g. egg crate) or an overall height of at least three inches if it is a non-convoluted overlay; and  
  • Foam with a density and other qualities that provide adequate pressure reduction; and  
  • Durable, waterproof cover.

Group I non-powered pressure-reducing mattresses are described by HCPCS codes E0184, E0186, E0187, E0196 and E0373.

A non-powered foam mattress (E0184) is characterized by all of the following:

  • Foam height of five inches or greater; and
  • Foam with a density and other qualities that provide adequate pressure reduction; and
  • Durable, waterproof cover; and
  • Can be placed directly on a hospital bed frame.

Non-powered pressure-reducing air, water or gel mattresses (E0186, E0187, E0196) are characterized by all of the following:

  • Height of five inches or greater of the air, water, or gel layer (respectively); and
  • Durable, waterproof cover; and
  • Can be placed directly on a hospital bed frame.

Group 1 powered pressure-reducing mattress overlay systems (alternating pressure or low air loss) are described by HCPCS codes E0180, E0181, E0182, E0372 and A4640. They are characterized by all of the following:

  • An air pump or blower, which provides both sequential inflation and deflation of air cells or a low interface pressure throughout the overlay; and
  • Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater; and
  • Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out (see Key Points section).

Group 2 - Special mattresses alone or fully integrated into a bed

HCPCS code E0277 describes a powered pressure-reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss), while E0193 describes a semi-electric or total electric hospital bed with a fully integrated powered pressure-reducing mattress.  These are characterized by all of the following:

  • An air pump or blower, which provides both sequential inflation and deflation of the air cells or a low interface pressure through the mattress; and
  • Inflated cell height of the air cells through which air is being circulated is five inches or greater; and
  • Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate patient lift, reduce pressure and prevent bottoming out (see Key Points section); and
  • A surface designed to reduce friction and shear; and
  • Can be placed directly on a hospital bed frame.

HCPCS code E0371 describes an advanced non-powered pressure-reducing mattress overlay that is characterized by all of the following:

  • Height and design of individual cells, which provide significantly more pressure reduction than a Group 1, overlay and prevent bottoming out; and
  • Total height of three inches or greater; and
  • A surface designed to reduce friction and shear; and
  • Documented evidence to substantiate that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces.

HCPCS code E0372 describes a powered pressure-reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure), which is characterized by all of the following:

  • An air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay; and
  • Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater; and
  • Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate patient lift, reduce pressure and prevent bottoming out (see Key Points section); and
  • A surface designed to reduce friction and shear.

HCPCS code E0373 describes an advanced pressure-reducing mattress, which is characterized by all of the following:

  • Height and design of individual cells that provide significantly more pressure reduction than a Group 1 mattress and prevent bottoming out; and
  • Total height of five inches or greater; and
  • A surface designed to reduce friction and shear; and
  • Documented evidence to substantiate that the product is effective for the treatment of conditions described by the medical criteria for coverage (see Policy section) for Group 2 support surfaces; and
  • Can be placed directly on a hospital bed frame.

Group 3 - Air Fluidized Beds

An air-fluidized bed (E0194) is a device employing the circulation of filtered air through silicone coated ceramic beads, creating the characteristics of fluid. When the patient is placed in the bed, his/her body weight is evenly distributed over a large surface area, which creates a sensation of floating.

KEY POINTS:

Patients needing pressure-reducing support surfaces should have a care plan which has been established by the patient’s physician or home care provider and is documented in the patient’s medical records and should generally include the following:

  1. Education of the patient and caregiver on the prevention and/or management of pressure ulcers; and
  2. Regular assessment by a nurse, physician, or licensed physical therapist; and
  3. Appropriate turning and positioning; and
  4. Appropriate wound care; and
  5. Appropriate management of moisture/incontinence; and
  6. Nutritional assessment and intervention consistent with the overall plan of care. 

“Bottoming out” is the finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and directly under the patient’s bony prominence (coccyx or lateral trochanter) can readily palpate the bony prominence.  This bottoming out evaluation should be conducted with the patient in the supine position with their head flat, in the supine position slightly elevated (no more than 30 degrees), and in the side-lying position.

The National Pressure Ulcer Advisory Panel Pressure Ulcer Stages was recently updated in 2016. 

A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

Pressure Ulcer Stages

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis.

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 3 Pressure Injury: Full-thickness skin loss

Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Pressure Injury:  Full-thickness skin and tissue loss

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss

Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

KEY WORDS:

Pressure-reducing support surfaces, mattress, mattress overlay, air-fluidized bed, powered pressure- reducing mattress overlay, foam overlay, non-powered pressure-reducing mattresses, pressure ulcer, pressure injury

PRACTICE GUIDELINES:

National Pressure Ulcer Advisory Panel (NPUAP)

Support surfaces are an important element in pressure ulcer treatment because they provide an environment that enhances perfusion of injured tissue. Support surfaces alone neither prevent nor heal pressure ulcers. They are to be used as part of a total management plan for pressure ulcer prevention and treatment.

Prevention and Treatment of Pressure Ulcers: Support Surfaces – an extract from the Clinical Practice Guideline:

http://www.internationalguideline.com/static/pdfs/02-NPUAP-EPUAP-PPPIA%20Support%20Surfaces%20Extract%20of%20the%20CPG%202017.pdf

Pressure Ulcer Staging:

https://cdn.ymaws.com/npuap.site-ym.com/resource/resmgr/npuap_pressure_injury_stages.pdf

US PREVENTIVE SERVICES TASK FORCE RECOMMENDATIONS:

Not applicable.

APPROVED BY GOVERNING BODIES:

Not applicable

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

HCPCS codes:           

A4640

Replacement pad for use with medically necessary alternating pressure pad owned by patient

E0181

Pressure pad, alternation with pump heavy duty

E0182

Pump for alternating pressure pad

E0184

Dry pressure mattress

E0185

Gel or gel-like pressure pad for mattress, standard mattress length and width

E0186

Air pressure mattress

E0187

Water pressure mattress

E0188

Synthetic sheepskin pad

E0189

Lambs wool sheepskin pad, any size

E0193

Powered air flotation bed (low air loss therapy)

E0194

Air fluidized bed

E0196

Gel pressure mattress

E0197

Air pressure pad for mattress, standard mattress length and width

E0198

Water pressure pad for mattress, standard mattress length and width

E0199

Dry pressure pad for mattress, standard mattress length and width

E0277

Powered pressure-reducing air mattress

E0371 

Nonpowered advanced pressure-reducing overlay for mattress, standard mattress length and width

E0372 Powered air overlay for mattress standard mattress length and width
E0373 Nonpowered advanced pressure-reducing mattress

REFERENCES:

  1. Blue Cross and Blue Shield Association.  Air fluidized beds.  Medical Policy Reference Manual, April 2003. 
  2. ECRI. Air-fluidized beds used for treatment of pressure ulcers in the home environment. Prepared by ECRI for the Agency for Healthcare Research and Quality (AHRQ). Health Technology Assessment No. 6. Rockville, MD: AHRQ; November 7, 2001.
  3. Institute for Clinical Systems Improvement (ICSI). Pressure ulcer prevention and treatment protocol. Health care protocol. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); January 2012.
  4. National Institute for Clinical Excellence (NICE). The prevention and treatment of pressure ulcers. Clinical Guideline No. 29. London, UK: NICE; 2005.
  5. National Pressure Ulcer Advisory Panel Pressure Ulcer Stages, http://www.npuap.org/pr2.htm. Accessed November 2019.
  6. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel. Pressure ulcer prevention recommendations. In: Prevention and treatment of pressure ulcers: clinical practice guideline.  Washington (DC): National Pressure Ulcer Advisory Panel; 2009. P. 21-50.
  7. National Pressure Ulcer Advisory Panel (NPUAP). Practice Guidelines 2014. http://www.internationalguideline.com/static/pdfs/02-NPUAP-EPUAP-PPPIA%20Support%20Surfaces%20Extract%20of%20the%20CPG%202017.pdf
  8. Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: A meta-analysis. Int Wound J. 2007;4(3):197-207.
  9. Nixon J, Nelson E A, Cranny G, et al.; PRESSURE Trial Group. Pressure relieving support surfaces: A randomised evaluation. Health Technol Assess. 2006;10(22):1-180.
  10. Palmetto GBA Local Medical Policy L11563
  11. Palmetto GBA Local Medical Policy L11564
  12. Palmetto GBA Local Medical Policy L11565
  13. Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers. WOCN Clinical Practice Guideline No. 2. Mount Laurel, NJ: Wound, Ostomy, and Continence Nurses Society (WOCN); June 1, 2010.

POLICY HISTORY:

Medical Policy Group, August 2005

Medical Policy Group, September 2005 (2)

Medical Policy Administration Committee, September 2005

Available for comment September 26-November 9, 2005

Medical Policy Group, August 2006 (1)

Medical Policy Group, March 2007 (1)

Medical Policy Administration Committee, April 2007

Medical Policy Group, July 2007 (1)

Available for comment August 3-September 17, 2007

Medical Policy Group, July 2009 (1)

Medical Policy Group, September 2011(3); Updated Key Points and References

Medical Policy Group, September 2012 (3): Effective September 14, 2012 this policy is no longer scheduled for regular literature reviews and updates.

Medical Policy Group, November 2019 (6): Updates to Description, Key Points, Practice Guidelines, Key Words (pressure ulcer, pressure injury) and References.

Medical Policy Group, December 2020 (6): Updates to Description, Key Points and References. No change to policy intent.

Medical Policy Group, April 2021 (6): Clarified policy statement to include approval timeframe for E0194. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the    

    patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and    

   4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent  

      therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.