Oscar Pressure-Reducing Support Surfaces (CG007) Form

Pressure injuries (pressure ulcers, pressure sores) are areas of skin and tissue damage that form in regions with unrelieved and/or increased pressure. Pressure injuries are often associated with prolonged immobility, poor nutrition, and/or comorbid medical conditions. Pressure-reducing support surfaces should be prescribed as a part of a comprehensive preventative or treatment plan to include proper skin and tissue care, repositioning and mobilization, and nutrition interventions. There are many pressure-reducing support surfaces used to care for and prevent the development of pressure injuries, including specialized mattresses and mattress overlays. The primary function of these support surfaces is to prevent focal areas of pressure and to better distribute the body surface over a larger area. Pressure-reducing support surfaces are categorized into three groups based on their features, such as the type of material and whether they are powered by electricity or not. Definitions “Pressure-Reducing Overlay” is a support surface designed to be placed directly on an existing support surface (either an ordinary mattress or hospital bed). “Pressure-Reducing Mattress” is a support surface designed to be placed directly on a hospital bed frame. 1 “Integrated Bed System” is a support surface and bed frame are combined into a single unit, where the integrated support surface is not capable of functioning separately. “Non-Powered Support Surface” is a passive support surface not requiring external energy for operation. “Powered Support Surface” is a support surface which requires A/C or D/C electrical power for operation. “Alternating Pressure” is powered pressure redistribution via cyclic changes in loading/unloading. “Low Air Loss” provides airflow to better manage the heat and humidity of the skin surface. “Group 1 Support Surfaces'' are pressure-reducing mattress overlays or mattresses that can be placed on top of a hospital bed, hospital bed frame or home mattress. They can be powered or non-powered. Group 1 support surfaces include the following: ○ Non-powered or passive pressure-reducing mattress ■ Include foam, air, water, or gel mattress having ALL of the following: 1. Material height of 5 inches or greater 2. Durable, waterproof cover 3. Ability to be placed directly on hospital bed frame 4. For foam mattresses only: properties that provides adequate pressure reduction (i.e., appropriate foam density) ○ Non-powered or passive pressure-reducing mattress overlays ■ Gel overlay: gel or gel-like layer height is 2 inches or greater ■ Air mattress overlay: interconnected air cells have height of 3 inches or greater when inflated ■ Water mattress overlay: filled height is 3 inches or greater ■ Foam mattress overlay: must have ALL of the following 1. If convoluted overlay (e.g., eggcrate): thickness 2 inches or greater plus peak height 3 inches or greater; if non-convoluted: overall height of 3 inches or greater 2. Foam with properties that provide adequate pressure reduction (i.e., appropriate foam density) 3. Durable, waterproof cover ○ Powered pressure-reducing mattress overlay ■ Alternating pressure or low air loss overlay having ALL of the following: 1. Air pump or blowing that provides sequential inflation/deflation of air cells or a low interface pressure throughout the overlay 2. A height of 2.5 inches or greater when inflated 2 3. Air chamber height, frequency of air cycling (for alternating pressure overlays), proximity of the air chambers to one another, and air pressure provide adequate member lift and pressure reduction “Group 2 Support Surfaces” are pressure-reducing mattress overlays or mattresses (alternating pressure or low air loss). They can be powered or advanced non-powered. These surfaces work by inflating tubes or cells with air. Group 2 support surfaces include the following: ○ Powered pressure-reducing mattress or overlay ■ Alternating pressure or low air loss mattress/overlay having ALL of the following: 1. Air pump or blowing that provides sequential inflation/deflation of air cells or a low interface pressure throughout the overlay 2. Inflated height of 3.5 inches or greater (for overlay); inflated height of 5 inches or greater (for mattress) 3. Air chamber height, frequency of air cycling (for alternating pressure overlays), proximity of the air chambers to one another, and air pressure provide adequate member lift and pressure reduction 4. Surface designed to reduce friction and shear 5. For mattress only: ability to be placed directly on hospital bed frame ○ Semi-electric hospital bed with powered pressure-reducing mattress: ■ Mattress must meet powered pressure-reducing mattress criteria above; and ■ The bed must function as an integrated bed-mattress system ○ Advanced non-powered passive pressure-reducing mattress or mattress overlay,which has ALL the following: ■ Height and design of individual cells provide a substantial improvement in the pressure reduction compared to Group 1 ■ 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 member lift, reduce pressure, and prevent bottoming out ■ Total height 3 inches or greater (for overlay); total height 5 inches or greater (for mattress) ■ A surface designed to reduce friction/shearing forces ■ Substantiated evidence of the effectiveness of the specific pressure relieving surface for treating conditions requiring a Group 2 support surface, as discussed in the “Clinical Indications” section below ■ For mattress only: ability to be placed directly on hospital bed frame “Group 3 Support Surfaces” are air-fluidized beds, which use warm air, under pressure, to set silicone coated ceramic beads in motion to simulate the movement of fluid. When the patient is placed in bed, body weight is evenly distributed over a large surface area, creating a floating sensation. 3 “Ordinary or Conventional (non-medical) Mattresses and Overlays” are typical furniture items that are normally of use to people who do not have an illness or injury. Although they may be air-filled, water-filled, gel-like or foam, ordinary mattresses and overlays are not primarily medical in nature. “Pressure Injury Staging” is a method of classifying tissue damage resulting from a pressure-induced wound. Stages are defined in this guideline as follows: Stage Description Stage I Localized area of non-blanching erythema with intact skin. May be more painful, a different texture or a different temperature compared to adjacent tissue. Stage II Partial-thickness skin loss with exposed dermis and a moist pink or red wound bed. May also present as an intact or ruptured serum-filled blister. Stage III Full-thickness skin loss. Subcutaneous fat and rolled wound edges may be visible, but bone, tendon and muscle should NOT be exposed. Slough or eschar may be present. Ulcer depth will vary by anatomical location. Stage IV Full-thickness skin and tissue loss with exposed bone, tendon, ligament, cartilage, and/or muscle. Rolled wound edges, tunneling, and undermining are often present. Slough or eschar may be present. Ulcer depth may vary by anatomical location. Can extend into muscle and/or supporting structures. Unstageable Full-thickness skin/tissue loss with overlying slough or eschar that prevents full evaluation of the depth and involvement of underlying structures. “Deep-Tissue Pressure Injuries” are localized regions of intact or non-intact skin with non-blanching deep red or purple discoloration. Most often due to damage of the underlying soft tissue due to pressure or shearing forces. Clinical Indications Pressure-Reducing Support Surfaces - General Criteria The Plan considers pressure-reducing support surfaces medically necessary when ALL of the following criteria are met: 1. A signed and dated order (prescription) is submitted by the provider documenting the medical necessity for the support surface; and 2. Medical records are submitted by the provider documenting the expected duration of the injury or condition. Equipment is medically necessary only for the duration of the injury or condition, and the Plan may determine whether a rental or purchase is appropriate based on the duration of medical necessity; and 4 3. The requested support surface is provided by an in-network DME provider; and 4. The requested support surface subtype meets the appropriate Group criteria below. Group 1 Support Surfaces The Plan considers Group 1 support surfaces medically necessary when General Criteria is met AND ONE of the criteria below are met: 1. Member is completely immobile (i.e., cannot change body position without assistance); or 2. Member has limited mobility (i.e., cannot independently change body position meaningfully enough to alleviate pressure) and has one or more of the following: a. Impaired nutritional status; or b. Fecal or urinary incontinence; or c. Altered sensory perception; or d. Compromised circulatory status. 3. Member has a pressure injury of any stage on the trunk or pelvis and has one or more of the following: a. Impaired nutritional status; or b. Fecal or urinary incontinence; or c. Altered sensory perception; or d. Compromised circulatory status. Group 2 Support Surfaces 1. The Plan considers Group 2 support surfaces medically necessary when General Criteria is met AND ONE of the criteria below are met: a. The member meets ALL of the following: i. ii. iii. Has several Stage II pressure injuries on the trunk or pelvis; and The injuries have worsened or not changed for at least the past 30 days; and Has been on a comprehensive ulcer treatment program for at least the past 30 days which must have included the use of an appropriate Group 1 support surface. b. The member has large or multiple Stage III or IV pressure injuries on the trunk or pelvis; or c. The member meets ALL of the following: i. Has had myocutaneous flap or skin graft performed in the last 60 days for a pressure injury on the trunk or pelvis; and ii. Has been on a Group 2 or Group 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (within the past 30 days); and d. The member has tried and failed (worsening of disease), or had no clinical improvement with a Group 1 mattress. 5 Group 2 Support Surface Treatment Duration 1. Group 2 support surfaces for members meeting the criteria for Group 2 Support Surfaces above are generally medically necessary for up to 60 days from the date of the surgery. 2. Continued use of a Group 2 support surface is generally medically necessary until the injury is healed. If healing fails to occur, documentation in the medical record should demonstrate a. Continued need for a Group 2 support surface for wound management; and b. Modifications in the care plan are being implemented to promote further healing. Group 3 Support Surfaces The Plan considers Group 3 support surfaces medically necessary when General Criteria is met AND ALL of the criteria below are met: 1. The support surface is being used as part of a comprehensive, documented pressure injury treatment plan; and 2. Member has a Stage III or IV pressure injury; and 3. Member is bedridden or chair bound as a result of severely limited mobility; and 4. Member would require institutionalization in the absence of an air-fluidized bed (i.e., placement in a skilled nursing facility or hospitalization); and 5. The necessity for the air-fluidized bed is based on a comprehensive assessment and evaluation of the member after conservative treatment has been attempted without success for at least 30 days. The evaluation generally must be performed within 1 week of initiation of therapy with the air-fluidized bed. Documentation should generally specify that the following components have been attempted as part of the conservative treatment plan: a. Education of member and caregiver on prevention and management of pressure injuries; and b. Appropriate frequency of turning and repositioning; and c. Appropriate management of moisture/incontinence; and d. Wound care appropriate to Injury stage, including debridement if applicable; and e. Use of a Group 2 support surface, when appropriate; and f. Nutritional assessment and intervention consistent with overall care plan; and g. Assessment by a nurse, physician, or other licensed health care practitioner at least weekly 6. A trained, adult caregiver available to assist with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental, dietary needs, prescribed treatments and medications, and management and support of the air-fluidized bed system and any potential problems with its maintenance and operation; and 7. A licensed physician directs the home treatment regimen, and re-evaluates and re-certifies the medical necessity for the air-fluidized bed on a monthly basis; and 8. All other alternative equipment options have been appropriately considered and ruled out. Group 3 Support Surface Treatment Duration 6 3. Continued use of a Group 3 support surface is generally considered medically necessary until the injury is healed. If healing fails to occur, documentation in the medical record should demonstrate: a. Continued need for a Group 3 support surface for wound management, and b. Modifications in the care plan are being implemented to promote further healing. Repair/Replacement of Pressure-Reducing Support Surfaces The Plan considers the repair or replacement of a mattress or overlay medically necessary when ALL of the following criteria are met: 1. The treating physician must document that the item being repaired continues to be reasonable and necessary; and 2. The treating physician or supplier must document that the repair is reasonable and necessary. Experimental or Investigational / Not Medically Necessary Ordinary or conventional (non-medical) mattresses and overlays are NOT considered medically necessary by the Plan. They are not considered medically necessary as they are not within the scope of the definition of Durable Medical Equipment (DME) because of the following reasons: They are not primarily medical in nature, are not primarily used in the treatment of disease or injury, and are normally of use to people who do not have an illness or injury. This applies to ordinary or conventional (non-medical) mattresses and overlays regardless of their composition or design. Group 3 Support Surfaces Group 3 Support Surfaces are NOT considered medically necessary by the Plan in the following circumstances: 1. Stage III or IV pressure injuries of the foot because the foot can be elevated to relieve pressure without the use of a specialized air-fluidized bed; or 2. The member has coexisting pulmonary disease - lack of an adequate back support prevents effective coughing and dry air inhalation may thicken pulmonary secretions; or 3. The member requires treatment with wet soaks or moist wound dressings that are not protected by an impervious covering, such as plastic wrap or other occlusive material; or 4. Structural support of the home in which the bed is to be installed cannot safely support the weight of the air-fluidized system (generally weighs 1600+ pounds); or 5. Home electrical system is unreliable or cannot support the required increase in electrical energy consumption; or 6. Caregiver is unwilling or unable to provide the level of care required for the member to use of an air-fluidized bed; or 7. Other known contraindications are present.