Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260), for the enrollee.
You asked the Plan to pre-approve the semi-electric hospital bed. You say that the durable medical equipment is medically necessary. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered medically necessary when the patient: 1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the semi-electric hospital bed. Our physician reviewer found based on the medical records provided there is no documentation that the patient's condition requires position of the body in ways not feasible in an ordinary bed. There is no documentation that the patient requires frequent changes in body position or a need for immediate changes in body position. There is no documentation that the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. There is no documentation that the semi-electric hospital bed is medically necessary for this patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260), for the enrollee.1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 3. Requires frequent changes in body position and/or has an immediate need for a change in body position. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the semi-electric hospital bed. Our physician reviewer found based on the medical records provided there is no documentation that the patient's condition requires position of the body in ways not feasible in an ordinary bed. There is no documentation that the patient requires frequent changes in body position or a need for immediate changes in body position. There is no documentation that the patient's condition requires special attachments that cannot be fixed and used on an ordinary bed. There is no documentation that the semi-electric hospital bed is medically necessary for this patient. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the semi-electric hospital bed have not been met. Therefore, we decided that the Plan does not have to pre-approve hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress (E0260), for the enrollee.