Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 1 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
Approved:
Mary Engrav, MD
Date:
08/28/2015
Description:
The term hospital bed applies to a type of bed that is adjustable to suit the particular needs of a patient.
There are four main categories of hospital beds:
1. Manual, fixed height: the bed has adjustable head and foot elevations, which are manipulated by
using the hand appliance (usually a crank), but does not have an adjustment for the height of the
bed. Side rails can be added for safety.
2. Manual, variable height: in addition to the ability to adjust the head and foot elevation, one can
also adjust the overall height of the bed by using a hand appliance (usually a crank).
3. Semi-Electric: has the ability to adjust the head and foot elevations by using electric controls, but
the height of the bed is adjusted by hand appliance (usually a crank).
4. Total Electric: has the ability to adjust all functions of the bed, head and foot elevations and height
of the bed with use of electric controls.
5. Heavy Duty: is designed to accommodate patients that weigh more than 350 pounds
Criteria: CWQI HCS-0034 (This criteria is consistent with CMS Guidelines for Hospital Beds and Accessories)
Note: Coverage for hospital beds and accessories is subject to plan benefits and limitations for durable
medical equipment (DME). Refer to applicable plan handbook for specific benefit information.
Manual, fixed height bed/ Manual, variable height bed will be covered to plan limitations when one or
more of the following indications are present and expected to last for at least 30 days:
1. The patient requires positioning in ways that cannot be accomplished in an ordinary bed due to
treatment option, pain control, presence of contractures, or post-operative positioning; or
2. The patient requires the head of the bed elevated more than 30 degrees most of the time due to a
medical condition (i.e. congestive heart failure, chronic pulmonary diseases or problems with
aspiration; or
3. The patient requires the use of equipment that has been designed for use in conjunction with a
hospital bed, such as traction.; and
4. The patient requires frequent changes in position or, due to body size, structure or level of
consciousness, the patient is difficult to move or reposition and may not be able to assist in
repositioning; and
5. For Manual variable height beds, the patient requires a bed height different than that provided by
the standard fixed height bed, such as for transfers to a chair or wheelchair or to assist the patient
in assuming a standing position.
Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 2 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
Semi-Electric beds (E0260, E0261, E0294, E0295, and E0329) will be covered to plan limitation when ALL of
the following indications are present:
1. The patient has one or more of the following indications:
a. The patient requires positioning in ways that cannot be accomplished in an ordinary bed.
This may be due to treatment options, pain control, presence of contractures, or postoperative positioning; or
b. The patient requires the head of the bed to be elevated more than 30 degrees most of the
time due to a medical condition (i.e. congestive heart failure, chronic pulmonary disease or
problems with aspiration). Other methods of elevating the head of the bed (i.e. pillows or
wedges) have been unsuccessful or have been found impractical for reasons other than
convenience; or
c. The patient requires the use of equipment that has been designed for use in conjunction
with a hospital bed, such as traction; or
d. The patient requires a bed height different from an ordinary bed for transfers to a chair or
wheelchair or to assist the patient in assuming a standing position.
2. The patient requires frequent changes in position or, due to body size, structure or level of
consciousness, the patient is difficult to move or reposition and may not be able to assist in
repositioning.
Total electric bed (E0265, E0266, E0296, E0297) will be covered to plan limitations when case-by-case
review indicates medical necessity based on unique and/or extreme circumstances. Authorization is always
required.
Note: Medicare does NOT cover Total Electric Beds
Heavy duty bed (E0301, E0303) will be covered to plan limitations when all of the following indications are
present:
1. One or more of the above indications for a manual fixed height bed are met; and
2. The patient weighs more than 350 pounds, but less than 600 pounds.
Extra heavy duty bed (E0302, E0304) will be covered to plan limitations when all of the following indications
are present:
1. One or more of the above indications for a manual fixed height bed are met; and
2. The patient weighs more than 600 pounds.
Hospital Bed Accessories:
1. Trapeze bar (E0910, E0940) may be covered to plan limitations when the patient is unable to
assume a sitting position independently due to a medical condition, and/or to change position for
any other medical reason.
Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 3 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
2. Heavy duty trapeze equipment (E0911, E0912) is covered if the patient meets the criteria for
regular trapeze equipment and the patient’s weight is more than 250 pounds.
3. Side rails (E0305, E0310) or safety enclosures (E0316) may be covered to plan limitations if the
patient is considered to be at risk for safety issues or, if the rails are an integral part of the bed.
4. Innerspring mattress (E0271) or foam rubber mattress (E0272) may be covered to plan limitations
as a replacement for a hospital bed or to accommodate unusual medical conditions. These will be
reviewed on a case-by-case basis.
a. Replacement mattress will be approved if the hospital bed has already been authorized and
the current mattress is unable to be repaired.
5. A bed cradle E0280) may be covered to plan limitations for a patient who has a condition which
requires freedom from weight of linen or non contact with linen, such as burns, gouty arthritis, skin
ulcerations or infection.
6. Hospital beds with built-in scales are considered medically necessary only for non-ambulatory
individuals who require frequent weight measurements.
Non-covered items:
1. Beds, mattresses, and/or supplies provided by a non-DME supplier. This includes all nonhospital
adjustable beds (i.e. Craftmatic Adjustable Bed, Adjust-A-Sleep Adjustable Bed, Simmons Beauty
rest Adjustable Bed, etc).
2. Institutional-type beds are not appropriate for home use. These include oscillating beds, springbase
beds, circulating beds, cage beds, and stryker frame beds.
3. Bed boards
4. Over-bed tables and trays are considered a convenience item and not medically necessary as their
use is not primarily medical in nature.
5. Bed elevators (i.e. blocks, lifters)
6. Bed rail pads
7. Bed wedges/pillows
8. Call switches
9. Water beds
10. Safety accessories such as bed enclosures or canopies
Medicare Reference:
LCD: L11572 Hospital Beds and Accessories
NCD: 280.7 Hospital Beds
LCA: A37079 Hospital Beds and Accessories
Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 4 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
Information to be Submitted with Pre-Authorization Request:
1. Chart notes from the treating physician
2. Diagnosis and expected length of duration for use of the hospital bed
3. Supporting information, which may determine the type of bed and/or accessories required
Applicable CPT/HCPC Codes:
HCPC Codes
E0250
E0251
E0255
E0256
E0260
E0261
E0265
E0266
E0270
E0271
E0172
E0290
E0291
E0292
E0293
E0294
E0295
E0296
E0297
E0300
E0301
Description
Hospital bed, fixed height, with any type side rails, with mattress
Hospital bed, fixed height, with any type side rails, without mattress
Hospital bed, variable height, hi-lo, with any type side rails, with mattress
Hospital bed, variable height, hi-lo, with any type side rails, without
mattress
Hospital bed, semi-electric (head and foot adjustment), with any type side
rails, with mattress
Hospital bed, semi-electric (head and foot adjustment), with any type side
rails, without mattress
Hospital bed, total electric (head, foot, and height adjustments), with any
type side rails, with mattress
Hospital bed, total electric (head, foot, and height adjustments), with any
type side rails, without mattress
Hospital bed, institutional type includes: oscillating, circulating and Stryker
frame, with mattress
Mattress, innerspring
Mattress, foam rubber
Hospital bed, fixed height, without side rails, with mattress
Hospital bed, fixed height, without side rails, without mattress
Hospital bed, variable height, hi-lo, without side rails, with mattress
Hospital bed, variable height, hi-lo, without side rails, without mattress
Hospital bed, semi-electric (head and foot adjustment), without side rails,
with mattress
Hospital bed, semi-electric (head and foot adjustment), without side rails,
without mattress
Hospital bed, total electric (head, foot, and height adjustments), without
side rails, with mattress
Hospital bed, total electric (head, foot, and height adjustments), without
side rails, without mattress
Pediatric crib, hospital grade, fully enclosed
Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350
Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 5 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
E0302
E0303
E0304
E0305
E0310
E0316
E0328
E0329
E0910
E0911
E0912
E0940
Review Date
11/2012
09/2013
12/2014
07/2015
pounds, but less than or equal to 600 pounds, with any type side rails,
without mattress
Hospital bed, extra heavy-duty, extra wide, with weight capacity greater
than 600 pounds, with any type side rails, without mattress
Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350
pounds, but less than or equal to 600 pounds, with any type side rails, with
mattress
Hospital bed, extra heavy-duty, extra wide, with weight capacity greater
than 600 pounds, with any type side rails, with mattress
Bedside rails, half-length
Bedside rails, full-length
Safety enclosure frame/canopy for use with hospital bed, any type
Hospital bed, pediatric, manual, 360 degree side enclosures, top of
headboard, footboard and side rails up to 24 inches above the spring,
includes mattress
Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures,
top of headboard, footboard and side rails up to 24 inches above the spring,
includes mattress
Trapeze
Trapeze bar, heavy-duty, for patient weight capacity greater than 250
pounds, attached to bed, with grab bar
Trapeze bar, heavy-duty, for patient weight capacity greater than 250
pounds, freestanding, complete with grab bar
Trapeze bar, freestanding, complete with grab bar
Revisions
Annual Review: Added table with review date,
revisions, and effective date.
Annual Review: No changes
Annual Review: No changes
Added Medicare Reference
Effective Date
12/01/2012
09/25/2013
12/3/2014
8/28/2015
References:
 Australian wound Management Association (AWMA), Pressure Ulcer Interest SubCommittee. Clinical Practice Guidelines for the Prediction and Prevention of Pressure
Ulcers. West Leederville, Australia: AWMA; 2001
 Centers for Medicare & Medicaid Services (CMS). Medicare coverage database. National
coverage determination for hospital beds (280.7). Accessed on February 24, 2012 at:
Moda Health
Medical Necessity Criteria
Origination Date: 5/00
Subject: Hospital Beds and Accessories
Page 6 of 6
Revision Date(s): 12/02, 12/03, 12/04,
12/05, 12/06, 01/08, 01/09, 2/11, 2/12,
11/12, 09/13, 11/14, 07/15
Developed By: Medical Criteria Committee
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http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.7&ncd_version=1&basket=ncd
%3A280%2E7%3A1%3AHospital+Beds
Cullum, N., Petherick, E. Pressure ulcers. (2007). BMJ Clinical Evidence. London, UK. BMJ
Publishing Croup; updated February 2007.
Marik, P. Fink, M. One good turn deserves another! Crit Care Med. 2002;30(9):21462148.
OMAP Administrative Rulebook & Provider Archive. Durable Medical Equipment.
1 October 2005. Accessed on February 24, 2012 at:
http:/www.dhs.state.or.us/policy/healthplan/history/dme/122rb1005.pdf.
Powell –Cope, G., Baptiste, A., Nelson, A. Modification of bed systems and use of
accessories to reduce the risk of hospital-bed entrapment. Rebail Nurs. 2005; 30(1);917.
Centers for Medicare and Medicaid Noridian Healthcare Solutions; Local coverage
Determination (LCD): Hospital Beds and Accessories (L11572); Original Effective Date
10/01/1993; Revision Effective Date 10/31/2014
Centers for Medicare and Medicaid National Coverage Determination (NCD_ for
Hospital Beds (280.7);
Centers for Medicare and Medicaid Noridian Healthcare Solutions; Local coverage
Article; Hospital Beds and Accessories –Policy Article- Effective October 2014 (A37079);
Original Effective Date 01/01/2006; Revision Effective Date 10/31/2014
Physician Advisors