CG-DME-15 Hospital Beds and Accessories

Clinical UM Guideline Subject: Hospital Beds and Accessories Guideline #: CG-DME-15 Publish Date: 06/28/2023 Status: Reviewed Last Review Date: 05/11/2023 Description

This document addresses the use of hospital beds, a specialty bed used primarily in the treatment of individuals with an illness or injury. Hospital bed accessories are durable medical equipment items used in conjunction with a hospital bed.

Note: Please see the following related document for additional information:

Clinical Indications

Hospital Beds

Medically Necessary: 

A fixed height hospital bed is considered medically necessary if one or more of the following criteria are met:

1. The individual has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain, prevent contractures, promote good body alignment or avoid respiratory infections.
2. The individual requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed.
3. The individual requires special attachments, such as traction equipment, that can only be attached to a hospital bed.

A variable height hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair, or standing position. This includes, but is not limited to:

1. Severe arthritis;
2. Fractured hips or other lower extremity injuries;
3. Spinal cord injuries;
4. Severe cardiac conditions;
5. Stroke.

A semi-electric hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height bed and requires frequent changes in body position or has an immediate need for a change in body position.

A heavy-duty, extra-wide hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height hospital bed and the individual’s weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed is considered medically necessary if the individual meets one or more of the criteria for a hospital bed and the individual’s weight exceeds 600 pounds.

An enclosed crib or enclosed bed is considered medically necessary for individuals with seizures, disorientation, vertigo, and neurological disorders, where the individual needs to be restrained to bed. Clinical documentation must be provided that states less invasive strategies (that is, bed rails, bed rail protectors, or environmental modifications) have been tried and have not been successful.

A request for a hospital grade, pediatric crib will be reviewed for medical necessity on an individual basis.

Not Medically Necessary:

If the above criteria are not met, the hospital bed will be considered not medically necessary.

A total electric hospital bed is considered not medically necessary. The height adjustment feature is considered to be a convenience feature.

Ordinary (Non-Hospital) beds are considered not medically necessary. An ordinary bed does not meet the definition of durable medical equipment as it is not primarily medical in nature and is not primarily used in the treatment of a disease or injury.

Power or manual lounge beds are considered not medically necessary since they are not primarily medical in nature and are considered to be a comfort or convenience item.

Bed Accessories

Medically Necessary:

Trapeze equipment is considered medically necessary if the individual is confined to bed and needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed. Heavy duty trapeze equipment is considered medically necessary if the individual meets the criteria for regular trapeze equipment and weighs more than 250 pounds.

A bed cradle is considered medically necessary when it is necessary to prevent contact with the bed coverings. This includes, but is not limited to individuals with burns, decubitus or diabetic ulcers, or gouty arthritis.

Side rails or safety enclosures (such as, frame/canopy) are considered medically necessary when they are required by the individual’s condition and they are an integral part of, or an accessory to, a hospital bed.

If an individual’s condition requires a replacement innerspring mattress or foam rubber mattress it will be considered medically necessary for an individual-owned hospital bed.

Not Medically Necessary:

The following bed accessories are considered not medically necessary since they are not primarily medical in nature, are not mainly used in the treatment of a disease or injury and are normally of use to people who do not have a disease or injury:

1. Bedboards;
2. Overbed table;
3. Bed baths, bed spectacles, bed trays/reading tables, call switches, foot boards, bed lapboards;
4. Side rails when requested with a non-hospital or ordinary bed.

Side rails or frame/canopy for use with a hospital bed are considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Hospital beds
When services may be Medically Necessary when criteria are met:

HCPCS

 

E0250-E0251

Hospital bed, fixed height, with any type side rails, with or without mattress

E0255-E0256

Hospital bed, variable height, hi-lo, with any type side rails, with or without mattress

E0260-E0261

Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with or without mattress

E0290-E0291

Hospital bed, fixed height, without side rails, with or without mattress

E0292-E0293

Hospital bed, variable height, hi-lo, without side rails, with or without mattress

E0294-E0295

Hospital bed, semi-electric (head and foot adjustment), without side rails, with or without mattress

E0300

Pediatric crib, hospital grade, fully enclosed, with or without top enclosure

E0301-E0304

Hospital bed, heavy duty/extra heavy duty (includes codes E0301, E0302, E0303, E0304)

E0328

Hospital bed, pediatric, manual, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above the spring, includes mattress

 

For the following code when specified as semi-electric:

E0329

Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above spring, includes mattress [specified as semi-electric]

 

 

ICD-10 Diagnosis

 

  All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

HCPCS

 

E0265-E0266

Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with or without mattress

E0296-E0297

Hospital bed, total electric, (head, foot and height adjustments), without side rails, with or without mattress

 

For the following code when specified as total electric:

E0329

Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of head board, foot board and side rails up to 24 inches above spring, includes mattress [specified as total electric]

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Accessories
When services may be Medically Necessary when criteria are met:

HCPCS

 

E0271-E0272

Mattress

E0280

Bed cradle, any type

E0305

Bed side rails, half-length

E0310

Bed side rails, full-length

E0316

Safety enclosure frame/canopy for use with hospital bed, any type

E0910

Trapeze bars, also known as Patient Helper, attached to bed, with grab bar

E0911

Trapeze bar, heavy duty, for patient weight capacity greater than 250 pounds, attached to bed, with grab bar

 

 

ICD-10 Diagnosis

 

  All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

HCPCS

 

E0273

Bed board

E0274

Over-bed table

E0315

Bed accessory: board, table or support device, any type

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Descriptions

A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.

A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.

A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.

A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.

An ordinary bed is one that is typically sold as furniture. It consists of a frame, box springs and mattress. It is a fixed height and has no head or leg elevation adjustments. It is normally for use in the absence of illness or injury.

Power or manual lounge beds, like other ordinary beds, are typically sold as furniture and are not considered durable medical equipment as they are used in the absence of illness or injury. The following are examples of lounge beds:

1. Craftmatic® Adjustable Bed;
2. Adjust-A-Sleep Adjustable Bed;
3. Electropedic® Adjustable Bed (Electropedic Beds, Burbank, CA);
4. Simmons® Beautyrest® Adjustable Bed (Simmons Bedding Company, Norcross, GA);
5. Adjustable, vibrating beds.

The U.S. Food and Drug Administration (FDA) in 2005 determined that the Vail Enclosure Bed poses a significant public health risk because individuals can become entrapped and suffocate, resulting in severe neurological damage or death. Vail Products, Inc of Toledo, Ohio, has permanently ceased manufacture, sale and distribution of all Vail enclosed bed systems.

The Centers for Medicare and Medicaid Services (CMS) criteria were utilized in the development of this document.

References

Peer Reviewed Publications:

1. Hampton S. Can electric beds aid pressure sore prevention in hospitals? Br J Nurs. 1998; 7(17):1010-1017.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on February 7, 2023.
   • Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005.
   • Hospital Beds. NCD #280.7. This is a longstanding national coverage determination. The effective date of this version has not been posted.
2. CGS Administrators, LLC. Jurisdiction D. Local Coverage Determination for Hospital Beds and Accessories (L33820). Revised 1/1/2020. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx.  Accessed on February 7, 2023.
3. U.S. Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH). Medical Devices. Hospital beds. Updated August 23, 2018. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/default.htm. Accessed on February 7, 2023.

Index

Hospital Beds and Accessories

History

Status

Date

Action

Reviewed

05/11/2023

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

Reviewed

05/12/2022

MPTAC review. Updated References section.

Revised

05/13/2021

MPTAC review. Clarified MN bed accessories statement for side rails or “safety enclosures (such as, frame/canopy)” when they are required by the individual’s condition and they are an integral part of, or an accessory to, a hospital bed. Revised NMN statement to address “side rails or” frame/canopy for use with a hospital bed when the above criteria are not met. Updated References section. Reformatted Coding section.

Reviewed

05/14/2020

MPTAC review. Updated References section.

Reviewed

06/06/2019

MPTAC review. Updated Description, Discussion and References sections.

Reviewed

07/26/2018

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date”. Updated Discussion and References sections.

Reviewed

08/03/2017

MPTAC review. Updated References section.

Revised

08/04/2016

MPTAC review. Updated formatted in clinical indications section. Defined an abbreviation in MN criteria. Updated References section. Removed ICD-9 codes from Coding section.

Reviewed

08/06/2015

MPTAC review. Updated References.

Reviewed

08/14/2014

MPTAC review. Description and Websites updated.

Reviewed

08/08/2013

MPTAC review. Websites and References updated.

 

01/01/2013

Updated Coding section with 01/01/2013 HCPCS descriptor change.

Reviewed

08/09/2012

MPTAC review. Websites and References updated.

Reviewed

08/18/2011

MPTAC review. Websites and References updated.

Reviewed

08/19/2010

MPTAC review. Websites and References updated.

Revised

08/27/2009

MPTAC review.

Removed not medically necessary statement addressing the Vail enclosure bed. Removed place of service. References updated.

Reviewed

08/28/2008

MPTAC review. References updated.

 

01/01/2008

Updated coding section with 01/01/2008 HCPCS changes.

Revised

08/23/2007

MPTAC review. Addition of medically necessary statement for enclosure beds. References and coding updated.

Revised

12/07/2006

MPTAC review. Enclosure beds moved from medically necessary to not medically necessary. Added medically necessary language addressing heavy duty trapeze equipment. References and coding updated.

New

12/01/2005

MPTAC initial guideline development.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

No Document

Anthem CO/NV

 

DME.211

Hospital Beds and Accessories

Anthem MW

04/08/2005

DME.004

Hospital Beds & Other Bed Accessories

Anthem ME

 

Benefit Detail

Hospital Bed

Anthem CT

10/01/2004

DME Coverage Criteria Guideline, Section D

Hospital Beds and Accessories

WellPoint Health Networks, Inc.

 

 

No Document

 

 

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