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Issue Number - Name
0094 - Group 3 Support Surfaces
Review Type
Complex
Claim Type
DME by supplier, DME by physician
Region and State
RAC 5
All States
Date Approved
2018-05-08

Description

An air-fluidized bed (Group III Pressure Reducing Support Surface) uses warm air under pressure to set small ceramic beads in motion which simulate the movement of fluid. When the patient is placed in the bed, his body weight is evenly distributed over a large surface area which creates a sensation of “floating.” Medicare payment for home use of the air-fluidized bed for treatment of pressure sores can be made if such use is reasonable and necessary for the individual patient. Group III Pressure Reducing Support Surfaces, HCPCS Code E0194, Air-Fluidized Bed is covered for the treatment of Stage III and Stage IV ulcers when the patient meets certain coverage criteria. This review will determine if the item provided was reasonable and necessary for the patient’s condition based on the documentation in the medical record

Affected Code(s)

  • CPT code, E0194

Applicable Policy References

  • Title XVIII of the Social Security Act, Section 1833 (e)
  • Title XVIII of the Social Security Act, Section 1862 (a)(1)(A)
  • 42 Code of Federal Regulations, Sections 405.980 (b)&(c) and Section 405.986
  • 42 Code of Federal Regulations, Section 410.38 (g)(3)
  • 42 Code of Federal Regulations, Section 410.38 (g)(4)
  • 42 Code of Federal Regulations, Section 424.57 (12)
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110 
  • CMS Pub. 100-03, Medicare National Coverage Determination Manual, Chapter 1, Section 280.8 
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50.13.4 
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26 
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9
  • CMS Pub. 100-08, Nationwide Local Coverage Determination 
  • CMS Policy Article A52468, Effective date 10/01/2015