Hospital Beds and Accessories (CG006) Form

Hospital beds for home use are a form of durable medical equipment (DME) available in a variety of adjustable designs to assist with patient positioning. Home hospital beds may be useful in the treatment of various medical diseases and conditions such as congestive heart failure, chronic pulmonary disease, quadriplegia or paraplegia, and pressure ulcers. Selection of the appropriate hospital bed for qualifying members is based on several sets of criteria and requires a prescription from a licensed provider. The two major purposes for hospital bed use are:

1. A medical condition requiring repositioning that cannot be accomplished with an ordinary bed.
2. To permit the attachment of medically necessary accessories or equipment that cannot be attached to an ordinary bed. When medically necessary, a number of accessories can be utilized with hospital beds to assist with ambulation, wound care, and patient safety. In addition, there are also a number of specialized mattresses and mattress overlays that can be used at home for the treatment and prevention of pressure-related wounds, which often occur in periods of prolonged bed rest, poor nutrition, and comorbid medical diseases (see CG007: Pressure-Reducing Support Surfaces). Definitions Hospital Bed Types and Configurations ● “Standard Fixed-Height Bed” is a bed with manual head and leg elevation adjustments but with a non-adjustable, fixed-height. 1 ● “Standard Variable-Height Bed” is a bed with manual head and leg elevation adjustments and a manually adjustable height. ● “Semi-Electric Bed” is a bed that has electric head and leg elevation adjustments with a manually adjustable height. Typically used when rapid adjustments or frequent changes in body position are required. ● “Full-Electric Bed” is a bed on which height, head and leg elevation are all electrically operated. ● “Heavy-Duty Bed” is a bed capable of supporting patients weighing between 350 and 600 pounds. Available in the above (1-4) configurations. ● “Extra Heavy-Duty Bed” is a bed capable of supporting patients weighing greater than 600 pounds. Available in the above (1-4) configurations “Pediatric Hospital Crib” is a hospital grade bed that may include an added safety enclosure. “Ordinary (Non-Hospital) Bed” is a typical furniture item often consisting of a mattress, box spring, and frame. Can be adjustable or non-adjustable, powered or non-powered, and built from various materials. “Specialized Beds” include, but are not limited to, oscillating beds, spring base beds, circulating beds, cage beds, stryker frame beds, fully enclosed beds, and turning beds. “Hospital-Bed Accessories” include the various forms of equipment that can be attached to or used in conjunction with hospital beds, as further defined below. Clinical Indications Adult Hospital Beds / Pediatric Hospital Crib or Bed - General Criteria The Plan considers hospital beds medically necessary when ALL of the following criteria are met:
3. A signed and dated order (prescription) is submitted by the provider documenting the medical necessity for the hospital bed; and
4. 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
5. The bed is provided by a network DME provider; and
6. The requested bed subtype meets the appropriate criteria below. Standard Fixed-Height Bed The Plan considers standard fixed-height beds medically necessary for members when the General Criteria is met and the member meets any ONE of the following criteria:
7. The member has a medical necessity (e.g., prevent contractures, promote proper alignment, avoid respiratory infections, or other relevant conditions) for repositioning that cannot be accomplished with an ordinary non-hospital bed (Note: Elevation of the head and/or upper body to less than 30 degrees does NOT usually require use of a hospital bed); or 2
8. The member requires body positioning that is not possible with an ordinary bed in order to alleviate pain; or
9. The member requires elevation of the head of the bed to greater than 30 degrees in order to treat and alleviate symptoms often due to congestive heart failure, chronic pulmonary disease, or recurrent aspiration; or
10. The member requires the attachment of accessories or equipment that cannot be fixed and used on an ordinary bed (e.g., traction equipment). Standard Variable-Height Bed The Plan considers standard variable-height beds medically necessary when the General Criteria is met and the member meets ALL of the following criteria:
11. One of the four criteria above for standard fixed-height beds is met; and
12. The member has ONE of the conditions listed below: a. Severe arthritis or other injuries to lower extremities such as fractured hip, where the member would need a variable height feature to place the feet on the floor for assistance with ambulation; or b. Severe cardiac conditions where the member is capable of leaving the bed but requires a variable height adjustment to avoid the strain of “jumping” up and down to get in and out of the bed; or c. Spinal cord injuries (including quadriplegic and paraplegic), multiple limb amputations, and those who have had a stroke, where the member is able to transfer from a bed to a wheelchair (with or without help) and is unable to do so independently from a non-variable-height bed; or d. Any other severely debilitating diseases and conditions where a variable height adjustment would be needed for the member to transfer to a chair, wheelchair, or standing position. Adult Semi-Electric Bed / Pediatric Semi-Electric Bed The Plan considers semi-electric beds medically necessary when the General Criteria is met and the member meets ALL of the following criteria:
13. One of the four criteria above for standard fixed-height beds is met; and
14. The member or caregiver can operate the controls; and
15. The member has a need for frequent adjustments or otherwise would require immediate adjustments and cannot tolerate a delay. Heavy-Duty Bed/Extra Heavy-Duty Bed The Plan considers heavy-duty and extra heavy-duty beds medically necessary when the General Criteria is met and the member meets the following criteria:
16. Heavy-duty bed a. Criteria for any of the above hospital bed subtypes is met; and b. The member weighs greater than 350 pounds and less than 600 pounds. 3
17. Extra heavy-duty bed a. Criteria for any of the above hospital bed subtypes is met; and b. The member weighs 600 pounds or more. Repair/Replacement of Beds The Plan considers the repair or replacement of a bed medically necessary when ALL of the following criteria are met:
18. The treating physician must document that item being repaired or replaced continues to be reasonable and medically necessary; and
19. The treating physician or supplier must document that the repair or replacement is reasonable and medically necessary. Hospital Bed Accessories: The Plan considers the following hospital bed accessories medically necessary when:
20. They are provided by a network DME provider; and
21. They are prescribed by a licensed treating provider; and
22. They meet the specific criteria set forth below. Bed Cradles The Plan considers bed cradles medically necessary when the member has a condition that requires prevention of contact with bed coverings. Conditions include but are not limited to acute gouty arthritis, pain from complex regional pain syndrome (CRPS), burns, or ulcers (pressure or diabetic). Bed Pans (autoclavable hospital type) The Plan considers reusable, autoclavable bed pans medically necessary when the member is bed-confined. Side Rails The Plan considers side rails medically necessary when:
23. The member has a condition that requires fall prevention, mobility assistance, or better accessibility to controls (e.g., seizures, vertigo, disorientation, or similar neurological disorders); and
24. They are an integral part of, or an accessory to, a medically necessary hospital bed. Safety Enclosures The Plan considers safety enclosures medically necessary when:
25. The member has a condition that places him/her at high risk for falls or climbing out of bed; and 2. It is an integral part of, or an accessory to, a medically necessary hospital bed. Trapeze Equipment The Plan considers trapeze equipment medically necessary when: 4 ● Regular Trapeze equipment
26. The member is bed-confined and needs a trapeze bar to sit up because of a. Respiratory conditions; or b. To change body position for other medical reasons; or c. To get in and out of bed.
27. An “attachable” trapeze bar is not considered medically necessary when used on an ordinary (non-hospital) bed. ● Heavy duty trapeze equipment
28. The member meets the criteria for regular trapeze equipment; and
29. The member weighs more than 250 pounds. Urinals The Plan considers urinals medically necessary when the member is bed-confined. Experimental or Investigational / Not Medically Necessary Beds
30. Full electric beds are NOT considered medically necessary as the electric height adjustment is considered a convenience factor.
31. Ordinary (non-hospital) beds are NOT considered medically necessary by the Plan. Ordinary beds are not considered durable medical equipment. They are not considered medically necessary as 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 beds regardless of their adjustability, material composition, and ability to attach various medical equipment.
32. Most specialized hospital beds are considered experimental and investigational as there is insufficient evidence in the peer-reviewed literature documenting their effectiveness and long-term outcomes relative to established therapies. Specialized hospital beds include, but are not limited to: a. Oscillating beds b. Spring base beds c. Circulating beds d. Cage beds e. Stryker frame beds f. Fully enclosed beds g. Turning beds
33. Custom hospital beds are NOT considered medically necessary by the Plan. Medical necessity is considered for standard equipment only. 5 Accessories The following accessories are not considered medically necessary as 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: ● Bed baths ● Bed boards (i.e., board inserted between bed spring and mattress to give extra support) ● Bed elevation blocks (i.e., blocks to elevate the head or foot of bed), unless without elevation of both the head and foot of the bed the member would otherwise be unable to transfer from a bed to a wheelchair (with or without help) and the bed height cannot be adjusted through other means ● Bed lifters (i.e., bed elevators) ● Bed railing pads (i.e., protection over bed railing) ● Bed spectacles (used for reading while lying flat in bed) ● Bed trays/reading tables ● Call switches (i.e., device to summon help) ● Foot boards (i.e., board at the end of the bed) ● Lap boards (i.e., board used on lap as a table or desk) ● Overbed tables ● Standard beds and mattresses made of allergy-free materials ● Side rails when used with an ordinary bed