Scope of Policy

This Clinical Policy Bulletin addresses safety items.

Policy Limitations and Exclusions

Most standard Aetna benefit plans specifically exclude coverage of safety items. Examples of safety items include adaptive full-length side safety rail (SleepSafe) beds, manual or electric safety bed systems (e.g., KayserBetten Secure Sleep Systems), bed exit monitors (bed alarms), bed rails, belts, car seats (e.g., Carrie Car Seat, Columbia Orthopedic Positioning Seat, Gorilla Postural Seat, Snug Seat, Traveller Plus, Special Tomato MPS Car Seat), Embrace2 seizure monitoring watch, Exersides Refraint System (upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion), fall detection systems, fire extinguishers, first aid kits, grab bars, harnesses, hearing protectors (ear plugs; e.g., DB blockers), helmets

(e.g., Danmar soft shell helmet), knee and elbow pads, restraints, safety goggles, service dogs, smoke and carbon monoxide detectors, telephone alert systems, and vehicular restraint systems (e.g., EZ-On Vest)).

Aetna standard HMO-based plans typically exclude "coverage furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury." Standard Aetna non-HMO plans typically exclude charges "for care furnished mainly to provide a surrounding free from exposure that can worsen the person's disease or injury." Under these plans, safety interventions and devices are excluded from coverage regardless of whether they are an integral and medically necessary component of the management of the member's condition.

Under non-standard plans that

exclude safety items, continuously worn prefabricated or custom-made soft or hard specialized medical protective helmets are considered medically necessary to prevent injury due to frequent, violent or uncontrolled seizures, balance disorders, head banging behaviors, or following cranial surgery. Annual replacement of the replacement liner is considered medically necessary and covered for persons who qualify for coverage of a specialized helmet.

Telephone alert systems are not covered because they are not considered by Aetna to fall within the contractual definition of DME in that they are normally of use in the absence of illness or injury. (Telephone alert systems relay pre-programmed messages to pre-determined telephone contacts when an individual activates a distress signal. The distress signal activator is worn as a necklace or bracelet). In addition, telephone alert systems are considered safety items, which are contractually excluded under most benefit plans. Telephone alert systems are also known as emergency medical alert button systems (e.g., AlertOne, Lifeline, etc.), Please check benefit plan descriptions for details.

Under nonstandard plans that

exclude safety items, grab bars that are affixed to a wall or floor, such as around the bathtub or toilet, are not covered under the standard exclusion for addition or alternations to a home, workplace or other environment. Please see benefit plan descriptions.

Under nonstandard plans that

exclude safety items, hospital bedside rails, hospital bed safety enclosure frames

, and enclosed hospital-grade pediatric cribs would be considered medically necessary for persons with neurocognitive or physical disabilities that place them at increased risk for falling from the bed. Under these plans, safety equipment (e.g., belt, harness or vest) would be considered medically necessary for persons with neurocognitive or physical disabilities that place them at increased risk for falls. Restraints (body, chest, wrist or ankle) and vehicular restraint systems would be considered medically necessary for persons with neurocognitive or physical disabilities that place them increased risk of injury.

Under nonstandard plans that

exclude safety items, safety and athletic prescription lenses and frames would be excluded from coverage under the standard vision exclusion. Please check benefit plan descriptions.

* A specialized helmet may be covered as a prosthetic of the skull when medically necessary after cranial surgery. For cranial remodeling helmets/bands for plagiocephaly, see

.

** For coverage of hospital bed safety enclosure frames that are part of a medically necessary hospital bed, see

.