Clinical UM Guideline

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:

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

A.  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; or
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; or
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 either of the following:

1. Requires frequent changes in body position; or
2. 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 if the individual needs to be restrained to bed, for example individuals with seizures, disorientation, vertigo, and neurological disorders including autism spectrum disorder. 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:

A hospital bed is considered not medically necessary when the above criteria have not been met.

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.

B.  Bed Accessories

Medically Necessary:

Trapeze equipment is considered medically necessary when the individual meets the following criteria:

1. Is confined to bed; and
2. Needs this device to sit up because of any of the following:
   1. A respiratory condition, or
   2. To change body position for other medical reasons; or
   3. 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.

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:

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.

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

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.

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.

Autism spectrum disorder (ASD) is a neurological and developmental disorder that affects communication, learning and behavior (National Institute of Mental Health, 2022). Individuals with ASD are at risk of placing themselves in danger by “wandering” or “eloping” (leaving a supervised, safe space). Elopement may be a significant contributor to mortality in individuals with ASD due to accidents, such as suffocation and drowning. A study by Anderson and colleagues (2012) of 1218 families of children with AЅD found that approximately one-half of these children had tried to elope at least once after four years of age. Night wandering is a special concern, and among parents of elopers, 43% reported the issue had prevented family members from getting a good night's sleep. An enclosed bed may provide a safe and secure environment at night to prevent wandering.

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

Peer Reviewed Publications:

1. Anderson C, Law JK, Daniels A, et al. Occurrence and family impact of elopement in children with autism spectrum disorders. Pediatrics. 2012; 130(5):870-877.
2. 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 January 28, 2025.
   • Durable Medical Equipment Reference List. NCD #280.1. Effective May 16, 2023.
   • 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 January 28, 2025.
3. National Institute of Mental Health. Autism Spectrum Disorder. Revised 2022. Available at: https://www.nimh.nih.gov/health/publications/autism-spectrum-disorder. Accessed on January 28, 2025.
4. 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 January 28, 2025.

Hospital Beds and Accessories

This Clinical UM Guideline is intended to provide assistance in interpreting Healthy Blue’s standard Medicaid benefit plan. When evaluating insurance coverage for the provision of medical care, federal, state and/or contractual requirements must be referenced, since these may limit or differ from the standard benefit plan. In the event of a conflict, the federal, state and/or contractual requirements for the applicable benefit plan coverage will govern. Healthy Blue reserves the right to modify its Policies and Guidelines as necessary and in accordance with legal and contractual requirements. This Clinical UM Guideline is provided for informational purposes. It does not constitute medical advice. Healthy Blue may also use tools and criteria developed by third parties, to assist us in administering health benefits. Healthy Blue’s Policies and Guidelines are intended to be used in accordance with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice.