Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi electric hospital bed, trapeze bar, and gel 
mattress. 
 
You asked the Plan to pre-approve a semi electric hospital bed, trapeze bar, and gel mattress. You say that the 
requested semi electric hospital bed, trapeze bar, and gel mattress are medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet criteria for the requested semi electric hospital bed, 
trapeze bar, and gel mattress. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. 
 
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 a semi electric hospital bed, trapeze bar, 
and gel mattress. Our reviewer says that the enrollee does not meet criteria for the requested semi electric 
hospital bed, trapeze bar, and gel mattress. Our physician reviewer found according to Medicare a semi-electric 
hospital bed is medically necessary when a patients condition must require frequent changes in body position 
and/or there may be an immediate need for a change in body position and the patient can operate the controls 
and cause the adjustments.  Exceptions may be made to this last requirement in cases of spinal cord injury and 
brain damaged patients. According to Medicare, trapeze equipment is covered if the member needs this device 
to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or 
out of bed.  
 
In this case, the documentation doesnt support that the member has a condition that requires frequent 
positioning of the bed and mattress to alleviate pain, promote good body alignment, prevent contractures or 
avoid respiratory infections in a way that an ordinary bed is not able to. Additionally, the documentation 
doesnt support that the member has a respiratory condition or needs to change body position for another 
medical condition.  She doesn't need the trapeze equipment to get out of bed. 
 
According to Medicare a pressure reducing support surface is medically necessary when the beneficiary is 
completely immobile or has limited mobility that does not allow them to independently make a change in body 
position that is significant enough to alleviate pressure and has additional risk factors for a pressure injury or 
that the beneficiary has any stage pressure ulcer on the trunk or pelvis and additional risk factors for worsening pressure injuries.  A group 2 support surface is covered if the beneficiary has multiple stage 2 pressure ulcers 
located on the trunk or pelvis and has failed to improve in the previous month with conservative treatment with 
a comprehensive ulcer treatment program.  A group 2 support surface may also be covered if the beneficiary 
has large or multiple stage 3 or 4 pressure ulcers on the trunk or pelvis or a myocutaneous flap or skin graft for 
a pressure ulcer on the trunk or pelvis within the past 60 days.  
 
In this case, the documentation doesnt support that the member has multiple stage 2 pressure ulcers located on 
the trunk or pelvis and has failed to improve in the previous month with conservative treatment with a 
comprehensive ulcer treatment program or a myocutaneous flap or skin graft. The requested DME is not 
medically necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi electric hospital bed, trapeze bar, and gel mattress have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a semi electric hospital bed, trapeze bar, and 
gel mattress.