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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 heavy duty and bariatric devices are included in the codes for pressure reducing support 
surfaces: E0193, E0277, E0371, E0372 and E0373. 
 
Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered 
flotation without low air loss) which is characterized by all of the following: 
 
    An air pump or blower which provides either sequential inflation and deflation of the air cells or a low 
interface pressure throughout the mattress, and 
    Inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and 
    Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for 
alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent 
bottoming out, and 
    A surface designed to reduce friction and shear, and 
    Can be placed directly on a hospital bed frame. 
You can find these rules in the Local Coverage Article Pressure Reducing Support Surfaces - Group 2 - Policy 
Article A52490. 
The rules say 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 2 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 appropriate group 1 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 3 or 4 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. You can find these rules in the 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.