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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 Air fluidized beds are covered for services rendered on or after: July 30, 1990.

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.

A decision that use of an air-fluidized bed is reasonable and necessary requires that:

- The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore;
- The patient is bedridden or chair bound as a result of severely limited mobility;
- In the absence of an air-fluidized bed, the patient would require institutionalization;
- The air-fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive assessment and evaluation of the patient after completion of a course of conservative treatment designed to optimize conditions that promote wound healing. This course of treatment must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in an institution as long as there is documentation available to verify that the necessary conservative treatment has been rendered.
- Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and which continue beyond 30 days, will not preclude coverage of air-fluidized bed. Should additional debridement again become necessary, while a patient is using an air-fluidized bed (after the first 30-day course of conservative treatment) that will not cause the air-fluidized bed to become non-covered. In all instances documentation verifying the continued need for the bed must be available.
- A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage;
- A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; and
- All other alternative equipment has been considered and ruled out.

Conservative treatment must include:

- Frequent repositioning of the patient with particular attention to relief of pressure over bony prominences (usually every 2 hours);
- Use of a specialized support surface (Group II) designed to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation;
- Necessary treatment to resolve any wound infection;
- Optimization of nutrition status to promote wound healing;
- Debridement by any means (including wet to dry dressings-which does not require an occulsive covering) to remove devitalized tissue from the wound bed;
- Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.

Home use of the air-fluidized bed is not covered under any of the following circumstances:

- The patient has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions);
- The patient requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material;
- The caregiver is unwilling or unable to provide the type of care required by the patient on an air-fluidized bed;
- Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1600 pounds or more);
- Electrical system is insufficient for the anticipated increase in energy consumption; or
- Other known contraindications exist.

Coverage of an air-fluidized bed is limited to the equipment itself. Payment for this covered item may only be made if the written order from the attending physician is furnished to the supplier prior to the delivery of the equipment. Payment is not included for the caregiver or for architectural adjustments such as electrical or structural improvement.

You can find this rule in the National Coverage Determination (NCD) for Air-Fluidized Bed Chapter 1, Section 280.8.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.