LCD - Hospital Beds And Accessories (L33820)

LCD - Hospital Beds And Accessories (L33820)

Coverage Indications, Limitations, and/or Medical Necessity

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For any item to be covered by Medicare, it must meet several requirements: it must be eligible for a defined Medicare benefit category, it must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and it must meet all other applicable Medicare statutory and regulatory requirements.

The purpose of a Local Coverage Determination (LCD) is to outline the “reasonable and necessary” criteria based on the provisions of the Social Security Act §1862(a)(1)(A).

In addition to the “reasonable and necessary” criteria in this LCD, there are other payment rules discussed in the following documents, which must be met for Medicare reimbursement:

• The LCD-related Standard Documentation Requirements Article.
• The LCD-related Policy Article.
• Refer to the Supplier Manual for additional documentation requirements.
• Refer to the DME MAC websites for additional bulletin articles and publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act §1862(a)(1)(A), are defined by the coverage indications, limitations, and/or medical necessity outlined below.

Hospital Beds Coverage

A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria are met:

1. The beneficiary has a medical condition requiring positioning of the body in ways not feasible with an ordinary bed, or
2. The beneficiary requires positioning of the body to alleviate pain, or
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or
4. The beneficiary requires traction equipment that can only be attached to a hospital bed.

A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and requires a bed height different from a fixed height bed to permit transfers to chair, wheelchair, or standing position.

A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one 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 (E0301, E0303) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds but does not exceed 600 pounds.

An extra heavy-duty hospital bed (E0302, E0304) is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.

A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered as the height adjustment feature is considered a convenience feature and thus not reasonable and necessary.

If documentation does not justify the medical need for the type of bed billed, payment will be denied as not reasonable and necessary.

If the beneficiary does not meet any of the coverage criteria for any type of hospital bed, it will be denied as not reasonable and necessary.

Accessories

Trapeze equipment (E0910, E0940) is covered if the beneficiary needs the device to sit up due to a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.

Heavy-duty trapeze equipment (E0911, E0912) is covered if the beneficiary meets the criteria for regular trapeze equipment and the beneficiary's weight is more than 250 pounds.

A bed cradle (E0280) is covered when it is necessary to prevent contact with bed coverings.

Side rails (E0305, E0310) or safety enclosures (E0316) are covered when required by the beneficiary's condition and are an integral part of, or an accessory to, a covered hospital bed.

If a beneficiary's condition requires a replacement innerspring mattress (E0271) or foam rubber mattress (E0272), it will be covered for a beneficiary-owned hospital bed.

General

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim will be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) base items requiring a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before delivering the DMEPOS item to the beneficiary. If a supplier delivers a DMEPOS item without a WOPD, the claim will be denied as not reasonable and necessary.

For DMEPOS base items requiring a WOPD and separately billed associated options, accessories, and supplies, the supplier must have received a WOPD listing the base item and all associated options, accessories, and supplies billed before delivery. Claims for separately billed items without a completed and signed WOPD of the base item before delivery will be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims not meeting coding guidelines will be denied as not reasonable and necessary/incorrectly coded.

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Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers must maintain POD documentation in their files. Proof of delivery documentation must be available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier will be denied as not reasonable and necessary.

Are Home Hospital Beds Covered by Medicare?

Navigating healthcare can be complex, especially regarding costs and coverage of essential equipment like home hospital beds. With an aging population, understanding what is and isn’t covered by insurance, specifically Medicare, is crucial.

This article clarifies Medicare’s coverage for home hospital beds, highlighting the requirements for obtaining one and potential gaps in coverage that might necessitate out-of-pocket expenses.

Understanding Medicare Coverage Basics

Medicare, a cornerstone of health insurance for many Americans, especially those aged 65 and over, can often appear as a maze of regulations and policies. Its primary goal, however, remains to provide essential medical coverage to those in need.

It’s essential to recognize the distinct parts of Medicare, each focusing on specific aspects of healthcare:

• Medicare Part A: Provides coverage for hospital stays, some types of home health services, hospice care, and skilled nursing facility stays.
• Medicare Part B: Covers doctor visits, preventive services, and durable medical equipment (DME) like home hospital beds.
• Medicare Part C: Also known as Medicare Advantage, it is an alternative offered by private companies and usually includes benefits from Parts A and B and sometimes Part D, plus additional services.
• Medicare Part D: Dedicated to prescription drug coverage.

Understanding Medicare often brings various supplemental benefits to light, such as the over-the-counter (OTC) card, available through some Medicare Advantage plans. But what exactly is an OTC card? It’s a prepaid card with a specific dollar amount, allowing beneficiaries to buy approved, non-prescription health items like vitamins or first-aid supplies, ensuring access to essential medical treatments and preventive products.

Medicare’s Coverage for Home Hospital Beds

Medicare Part B can be a valuable resource when it comes to accessing critical equipment like home hospital beds, provided certain criteria are met.

Firstly, the bed must be a medical necessity, meaning the patient’s condition requires features not available in a standard bed, such as side rails, adjustable height, or elevation capabilities.

Here are the main requirements for Medicare to cover home hospital beds:

• Doctor’s Prescription: A physician must prescribe the bed, specifying its medical necessity. The prescription should detail why the patient’s condition requires a special bed and why alternatives are not suitable.
• Approved Supplier: The bed must be purchased from a Medicare-approved supplier to ensure it meets medical standards.
• Coverage Percentage: Medicare typically covers 80% of the approved amount under Part B, with the remaining 20% and the Part B deductible being the beneficiary’s responsibility.

Limitations of Medicare-Covered Beds

While Medicare can help reduce the financial burden of acquiring a hospital bed, it's important to understand potential limitations in terms of features and aesthetics.

Basic Functionality

Medicare-covered beds primarily provide basic medical support without advanced features like massage functions or enhanced adjustability.

Aesthetic Appeal

These beds often retain a clinical appearance, which might not blend well with home interiors, making the space feel more like a hospital.

Durability and Quality

Although meeting Medicare standards, these beds may not include the highest quality or most recent models, potentially leading to quicker wear and more frequent maintenance.

Limited Customization

Choices may be limited in terms of size, design, or additional features, which may not cater to individual preferences.

Potential Future Costs

Additional costs for upgrades or add-ons to enhance comfort or functionality may be required, leading to further out-of-pocket expenses.

Alternative Options

Considering the need for a hospital bed at home, Medicare is just one of several avenues available.

Renting a hospital bed can be a cost-effective and flexible option, particularly for short-term needs like post-operative recovery or during temporary ailments. Rental providers often offer a variety of models, from basic to luxury features.

Alternatively, purchasing a premium bed might be appealing, especially for those willing to pay out-of-pocket. This allows for selecting beds based on quality, features, and aesthetics, promoting holistic well-being and comfort.

Wrapping Up

While Medicare can provide coverage for home hospital beds, it typically covers only basic models, which might not meet everyone’s expectations. This underscores why many individuals opt to invest personally in a premium bed that aligns with their comfort, aesthetics, and personal preferences. Balancing medical necessity with a sense of home often makes the value of a premium bed surpass standardized Medicare options.

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