A hospital bed is a bed with head and leg elevation and, in some cases, height adjustment features that are used to assist individuals who require adjustment or repositioning.

Manual/Fixed Hospital Beds with/without variable height feature
A manual hospital bed without variable height feature (also known as a fixed height hospital bed) may be considered medically necessary when any ONE of the following criteria is met:

• The  individual’s condition requires positioning of the body, e.g., to alleviate pain, promote good body alignment, prevent contractures and/or avoid respiratory infections, in ways not feasible in an ordinary bed; or
• The individual’s  condition requires special attachments that cannot be fixed and used on an ordinary bed; or
• 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.  

A manual hospital bed with a variable height feature may be considered medically necessary when BOTH of the following conditions are met:

• The individual meets one of the criteria for a fixed height hospital bed; and
• The individual requires a bed height different than a fixed height bed to permit transfers to a chair, wheelchair or standing position.

A manual hospital bed is considered not medically necessary when above criteria are not met.

Semi-Electric Hospital Beds
A semi-electric hospital bed may be considered medically necessary when ALL of the following criteria are met:

• The individual meets all requirements for a standard hospital bed; and
• The  individual’s  condition requires frequent and/or immediate change in body position (i.e., no delay can be tolerated); and
• The individual can operate the controls himself, with the exception of spinal cord disease or injury, or brain damaged individuals.

Semi-electric beds are considered not medically necessary when above criteria are not met.

A semi-electric hospital bed which is provided and/or prescribed because of the absence or inability of a person caring for the individual, for aesthetic reasons, or for added convenience will be denied as non-covered.  When a semi-electric hospital bed is provided but is not prescribed by the individual’s physician, the claim should be processed for the type of bed that was prescribed.

A power chair conversion bed (e.g., The Total Care Bariatric Bed) is considered a convenience feature and therefore non-covered.

Total Electric Beds

A total electric bed is considered non-covered because the height and adjustment features are a convenience feature.

Powered Air Flotation Beds (Low Air Loss Therapy)
Powered air flotation beds may be considered medically necessary for individuals in the third or fourth stages of decubitus ulceration and who meet all of the requirements for a manual hospital bed.

Instituational beds under the brand name of Flexicair will be denied as non-covered because they are inappropriate for home use. The appropriateness of all other brands of powered air flotation beds for use in the home must be established on an individual consideration basis.

Power Air Flotations Beds (Low Air Loss Therapy) are considered not medically necessary when the above criteria are not met.

Air-Fluidized Beds (Bead Bed)

Use of air-fluidized beds, for treatment of pressure sores may be considered medically necessary following a medical review for ALL of the following conditions:

• The  individual has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore; and
• The individual is bedridden or chair bound as a result of severely limited mobility; and
• In the absence of an air-fluidized bed, the individual would require institutionalization; and
• 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 conservative treatment has been tried without success; and
• 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 potential problems such as leakage; and
• A physician directs the home treatment regimen and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; and
• All other alternative equipment has been considered and ruled out.

An Air-Fluidized Bed (Bead Bed) is considered not medically necessary when above the criteria are not met.

Institutional Beds

The following institutional beds are considered not suitable for home use and are therefore non-covered:

• Oscillating Bed; or
• Stryker Frame; or
• Springbase Bed; or
• Circulating Bed; or
• Rotational Beds; or
• Cage Beds.

Fully Enclosed Pediatric Cribs or Pediatric Hospital Beds with 360^o Side Enclosures
A fully enclosed pediatric crib (manual or electric) or a pediatric hospital bed (manual or electric) with 360^o side enclosures may be considered medically necessary following a medical review.

A fully enclosed pediatric crib bed not meeting patient criteria will be considered not medically necessary.

Safety Beds
A safety bed (manual or electric) may be considered medically necessary for the primary indication of an individual’s safety in the home determined by medical review that the individual’s condition is so severe that injury may occur without use of the safety bed.

Any claims for a safety bed not meeting the patient criteria will be considered not medically necessary.

Heavy Duty Hospital Beds
A heavy duty extra wide hospital bed may be considered medically necessary following a medical review when ALL of the following criteria have been met:

• The individual has met one 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 may be considered medically necessary following a medical review when ALL of the following criteria have been met:

• The individual has met one of the criteria for a fixed height hospital bed; and
• The individual’s weight exceeds 600 pounds.

Heavy duty hospital beds are considered not medically necessary when the above criteria is not met.

Mattress
A mattress is considered medically necessary only when a hospital bed has been determined medically necessary. (Separate charge for replacement mattress should not be allowed when a hospital bed is rented.)

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

Bed Accessories
The following hospital bed-accessories may be considered medically necessary when a hospital bed has been determined medically necessary:

• Bed cradles: as long as the cradles are not used as a personal comfort item.
• Bed pans: if the individual is bed confined.
• Bed rails: only when the rails are an integral part of a hospital bed.
• Safety Enclosure Frame/Canopy for Use with Hospital Bed, following a medical review.
• Trapeze bars/bases: if the member is bed-confined and needs a trapeze bar to sit up because of respiratory conditions, to change body position for other medical reasons, or to get in and out of bed.
• Built-in Weight Scale*.

*A hospital bed with a built-in scale is considered medically necessary ONLY for non-ambulatory individuals who require periodic weight measurements.

Hospital bed accessories not meeting the above criteria are considered not medically necessary.

The following accessories and related items as they are considered comfort or convenience items and therefore are considered non-covered:

• Bed baths; or
• Bed boards; or
• Bed lifter; or
• Bed lounge; or
• Over bed tables.

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME.