For any item to be covered by Medicare, it must: 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed
body member, and 3) meet all other applicable Medicare statutory and
regulatory requirements.  
  
The purpose of a Local Coverage Determination (LCD) is to provide information
regarding "reasonable and necessary" criteria based on Social Security Act 
1862(a)(1)(A) provisions.  
  
In addition to the "reasonable and necessary" criteria contained in this LCD
there are other payment rules, which are discussed in the following documents,
that must also be met prior to Medicare reimbursement:

  * The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
  * The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
  * Refer to the Supplier Manual for additional information on documentation requirements.
  * Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

  
For the items addressed in this LCD, the "reasonable and necessary" criteria,
based on Social Security Act  1862(a)(1)(A) provisions, are defined by the
following coverage indications, limitations and/or medical necessity.  
  
A Group 1 mattress overlay or mattress (E0181, E0182, E0184, E0185, E0186,
E0187, E0188, E0189, E0196, E0197, E0198, E0199 and A4640) is covered if one
of the following three criteria are met:

  1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
  2. The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
  3. The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

Conditions for criteria 2 and 3 (in each case the medical record must document
the severity of the condition sufficiently to demonstrate the medical
necessity for a pressure reducing support surface):

  1. Impaired nutritional status
  2. Fecal or urinary incontinence
  3. Altered sensory perception
  4. Compromised circulatory status

When the coverage criteria for a Group 1 mattress overlay or mattress are not
met, the claim will be denied as not reasonable and necessary.  
  
The support surface provided for the beneficiary should be one in which the
beneficiary does not "bottom out". Bottoming out is the finding that an
outstretched hand, placed palm up between the undersurface of the mattress
overlay or mattress and the beneficiary's bony prominence (coccyx or lateral
trochanter), can readily palpate the bony prominence. This bottoming out
criterion should be tested with the beneficiary in the supine position with
their head flat, in the supine position with their head slightly elevated (no
more than 30 degrees), and in the side-lying position.  
  
A support surface which does not meet the characteristics specified in the
Coding Guidelines section of the Policy Article will be denied as not
reasonable and necessary.  
  
  
GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a
claim is submitted. If the supplier bills for an item addressed in this policy
without first receiving a completed SWO, the claim shall be denied as not
reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
base items that require a Written Order Prior to Delivery (WOPD), the supplier
must have received a signed SWO before the DMEPOS item is delivered to a
beneficiary. If a supplier delivers a DMEPOS item without first receiving a
WOPD, the claim shall be denied as not reasonable and necessary. Refer to the
LCD-related Policy Article, located at the bottom of this policy under the
Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed
associated options, accessories, and/or supplies, the supplier must have
received a WOPD which lists the base item and which may list all the
associated options, accessories, and/or supplies that are separately billed
prior to the delivery of the items. In this scenario, if the supplier
separately bills for associated options, accessories, and/or supplies without
first receiving a completed and signed WOPD of the base item prior to
delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines
listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC
articles. Claims that do not meet coding guidelines shall be denied as not
reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are
required to maintain POD documentation in their files. Proof of delivery
documentation must be made available to the Medicare contractor upon request.
All services that do not have appropriate proof of delivery from the supplier
shall be denied as not reasonable and necessary.

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