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 fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered
if one or more of the following criteria (1-4) are met:

  1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
  2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
  3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or
  4. The beneficiary requires traction equipment, which can only be attached to a hospital bed.

A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if
the beneficiary meets one of the criteria for a fixed height hospital bed and
requires a bed height different than a fixed height hospital bed to permit
transfers to chair, wheelchair or standing position.

A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is
covered if the beneficiary meets one of the criteria for a fixed height bed
and requires frequent changes in body position and/or has an immediate need
for a change in body position.

A heavy duty extra wide hospital bed (E0301, E0303) is covered if the
beneficiary meets one of the criteria for a fixed height hospital bed and the
beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed (E0302, E0304) is covered if the beneficiary
meets one of the criteria for a hospital bed and the beneficiary's weight
exceeds 600 pounds.

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.

For any of the above hospital beds (plus those coded E1399 - see Policy
Article Coding Guidelines), if documentation does not justify the medical need
of the type of bed billed, payment will be denied as not reasonable and
necessary.

If the beneficiary does not meet any of the coverage criteria for any type of
hospital bed it will be denied as not reasonable and necessary.

  
ACCESSORIES:

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.

Heavy duty trapeze equipment (E0911, E0912) is covered if the beneficiary
meets the criteria for regular trapeze equipment and the beneficiary's weight
is more than 250 pounds.

A bed cradle (E0280) is covered when it is necessary to prevent contact with
the bed coverings.

Side rails (E0305, E0310) or safety enclosures (E0316) are covered when they
are required by the beneficiary's condition and they are an integral part of,
or an accessory to, a covered hospital bed.

If a beneficiary's condition requires a replacement innerspring mattress
(E0271) or foam rubber mattress (E0272) it will be covered for a beneficiary
owned hospital bed.

  
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.