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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that a group 2 support surface is covered if the beneficiary meets at least one of the following 
three Criteria (1, 2 or 3): 
 
    1. The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the ICD-10 
code list section in the LCD-related Policy Article for applicable diagnoses) which have failed to improve over 
the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program 
including each of the following: 
       a. Use of an appropriatge group1 support surface, and 
       b. Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and 
        c. Appropriate turning and positioning, and 
        d. Appropriate wound care, and 
        e. Appropriate management of moisture/incontinence, and 
        f. Nutritional assessment and intervention consistent with the overall plan of care 
    
2. The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the ICD-
10 code list section in the LCD-related Policy Article for applicable diagnoses), 
    
3. The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the 
past 60 days (refer to the ICD-10 code list section in the LCD-related Policy Article for applicable diagnoses), 
and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing 
facility within the past 30 days. 
 
If the beneficiary is on a group 2 surface, there should be a care plan established by the treating practitioner or 
home care nurse which includes the above elements. The support surface provided for the beneficiary should be 
one in which the beneficiary does not "bottom out" (see Appendices section). 
 
When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited 
to 60 days from the date of surgery. 
 
When the stated coverage criteria for a group 2 mattress or bed are not met, a claim will be denied as not 
reasonable and necessary. 
 
A support surface which does not meet the characteristics specified in the Coding Guidelines section of the 
Pressure Reducing Support Surfaces Group 2 Policy Article will be denied as not reasonable and necessary. 
(See Policy Article sections concerning billing of E1399.) 
 
Continued use of a group 2 support surface is covered until the ulcer is healed, or if healing does not continue, 
there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified 
to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound 
management. 
 
Appropriate use of the KX modifier (see Modifier section in the related Policy Article) is the responsibility of 
the supplier. The supplier should maintain adequate communication on an ongoing basis with the clinician 
providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical 
conditions which meet the criteria for coverage of a group 2 support surface, and that adequate documentation 
exists in the medical record reflecting these conditions. Such documentation should not be submitted with a 
claim but should be available upon request. 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Pressure Reducing Support 
Surfaces - Group 2 (L33642). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.