CG-DME-16 Pressure Reducing Support Surfaces - Groups 1, 2 & 3 Form

This document addresses the use of pressure reducing support surfaces. A pressure reducing support surface is designed to prevent or promote the healing of certain types of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site.

Clinical Indications

Group 1 Support Surfaces (as defined in the Definition Section)

Medically Necessary:

Use of a group 1 mattress overlay or mattress is considered medically necessary if the individual meets:

1. Criterion 1, or
2. Criterion 2 or 3 and at least one of criteria 4-7
   1. Completely immobile – that is, individual cannot make changes in body position without assistance
   2. Limited mobility – that is, individual cannot independently make changes in body position significant enough to alleviate pressure
   3. Any stage pressure ulcer on the trunk or pelvis
   4. Impaired nutritional status
   5. Fecal or urinary incontinence
   6. Altered sensory perception
   7. Compromised circulatory status

Group 2 Support Surfaces (as defined in the Definition Section)

Medically Necessary:

1. Criteria 1 and 2 and 3, or
2. Criterion 4, or
3. Criteria 5 and 6
   1. Multiple stage II pressure ulcers located on the trunk or pelvis
   2. Individual has been on a comprehensive ulcer treatment program (*see below) for at least the past 30 days that has included the use of an appropriate group 1 support surface
   3. The ulcers have worsened or remained the same over the past month
   4. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis
   5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days)
   6. The individual has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

*The comprehensive ulcer treatment program described above should generally include:

• Education of the individual and caregiver on the prevention and/or management of pressure ulcers
• Regular assessment by a nurse, physician or other licensed healthcare practitioner (usually at least weekly for an individual with a stage III or IV ulcer)
• Appropriate turning and positioning
• Appropriate wound care (for a stage II, III or IV ulcer)
• Appropriate management of moisture/incontinence
• Nutritional assessment and intervention consistent with the overall plan of care

Continued use of a group 2 support surface is considered medically necessary until the ulcer is healed or, 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.

When a group 2 pressure reducing support surface is prescribed following a myocutaneous flap or skin graft, continued use is considered medically necessary for up to 60 days from the date of surgery.

Group 3 Support Surfaces (as defined in the Definition Section)

Medically Necessary:

Use of a group 3 support surface (air-fluidized bed) is considered medically necessary if the individual meets all of the following:

1. The individual has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure sore or is status post muscle/skin flap repair of a stage III or IV pressure sore. An air-fluidized bed is typically needed only 6-12 weeks status-post surgery; and
2. The individual is bedridden or chair bound as a result of severely limited mobility; and
3. In the absence of an air-fluidized bed, the individual would require institutionalization; and
4. The air-fluidized bed is ordered, in writing, by the individual’s attending physician based upon a comprehensive assessment and evaluation of the individual after completion of a course of conservative treatment designed to optimize conditions that promote wound healing; and
5. The course of conservative treatment (*see below) must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment was rendered; and
6. A trained adult caregiver is available to assist the individual 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
7. A physician directs the home treatment regimen and re-evaluates and re-certifies the need for the air-fluidized bed every three months; and
8. All other alternative equipment has been considered and ruled out.

*Conservative treatment must include:

• Frequent repositioning of the individual with particular attention to relief of pressure over bony prominences (usually every two hours); and
• Use of a group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and
• Necessary treatment to resolve any wound infection; and
• Optimization of nutrition status to promote wound healing; and
• Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the wound bed; and
• Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering while the wound heals.

Wet-to-dry dressings, when used for debridement, do not require an occlusive dressing. Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days, does not in and of itself affect the medical necessity of an air-fluidized bed. Should additional debridement again become necessary while the individual is using an air-fluidized bed (after the first 30-day course of conservative treatment) that will not in and of itself affect the medical necessity of an air-fluidized bed.

In addition, conservative treatment should generally include:

• Education of the individual and caregiver on the prevention and management of pressure ulcers
• Assessment by a physician, nurse or other licensed healthcare practitioner at least weekly
• Appropriate management of moisture or incontinence

Continued use of an air-fluidized bed is considered medically necessary until the ulcer is healed or, 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 air-fluidized bed is medically necessary for wound management.

Not Medically Necessary:

Use of a group 1 or group 2 overlay, mattress, or bed is considered not medically necessary when the criteria above are not met.

Use of a group 3 support surface (air-fluidized bed) is considered not medically necessary under any of the following circumstances:

1. The individual has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions)
2. The individual requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material
3. The caregiver is unwilling or unable to provide the type of care required by the individual on an air-fluidized bed
4. Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1600 pounds or more)
5. Electrical system is insufficient for the anticipated increase in energy consumption
6. Other known contraindications exist

Use of a support surface (group 1 or group 2) that does not meet the characteristics specified in the Definition section of this document is considered not medically necessary.