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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 an air-fluidized bed is covered only if all of the following criteria are met: 
 
The beneficiary has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure ulcer. 
 
The beneficiary is bedridden or chair bound as a result of severely limited mobility. 
 
In the absence of an air-fluidized bed, the beneficiary would require institutionalization. 
 
The air-fluidized bed is ordered in writing by the beneficiarys treating practitioner based upon a 
comprehensive assessment and evaluation of the beneficiary after completion of a course of conservative 
treatment designed to optimize conditions that promote wound healing. The evaluation generally must be 
performed within one month prior to initiation of therapy with the air-fluidized bed. 
 
The course of conservative 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 was rendered. 
Conservative treatment must include: 
 
* Frequent repositioning of the beneficiary with particular attention to relief of pressure over bony prominences 
(usually every 2 hours); and 
* Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new 
ulcer formation; and 
* Necessary treatment to resolve any wound infection; and 
* Optimization of nutrition status to promote wound healing; and 
* Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the 
wound bed; and 
* Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an 
occlusive covering, while the wound heals. 
 In addition, conservative treatment should generally include: 
 
* Education of the beneficiary and caregiver on the prevention and management of pressure ulcers; and 
* Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly, and 
* Appropriate management of moisture/incontinence. 
 
Wet-to-dry dressings when used for debridement do not require an occlusive dressing. 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 an air-fluidized bed. Should additional debridement again 
become necessary while a beneficiary is using an air-fluidized bed (after the first 30-day course of conservative 
treatment) that will not cause the air-fluidized bed to be denied. 
 
All other alternative equipment has been considered and ruled out. 
 
If the stated coverage criteria for an air-fluidized bed are not met, the claim will be denied as not reasonable 
and necessary. 
 
You can find these rules in the Local Coverage Determination (LCD) Pressure Reducing Support Surfaces - 
Group 3 L33692. 
 
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.