Appeal type: unknown
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. 
 
A total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height adjustment feature is 
a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
 
Trapeze equipment (E0910, E0940) is covered if the beneficiary 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. 
 
You can find this information in Centers for Medicare and Medicaid Services, Local Coverage Determination 
(LCD): Hospital Beds and Accessories (L33820). 
 
Heavy duty and bariatric devices are included in the codes for pressure reducing support surfaces: E0193, 
E0277, E0371, E0372 and E0373. 
 
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 this information in Centers for Medicare and Medicaid Services, 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.