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Thread: Did insurance pay for your low air loss mattress and bed?

  1. #1

    Did insurance pay for your low air loss mattress and bed?

    If yes, was it a hassle getting them to pay? I have BCBS insurance.

    Thanks in advance!
    Renee

  2. #2
    Virtually all insurances except perhaps workers' comp and perhaps the VA follow Medicare guidelines when it comes to these types of mattresses. They put mattresses/support systems into 3 categories. A LAL mattress (code E0193) is considered a Group 2 type mattresses. Here are the Medicare criteria for use:

    Group 1 Support Surfaces (as defined in the Definition Section)
    Medically Necessary:
    A group 1 mattress overlay or mattress is considered medically necessary if the individual meets:

    • Criterion 1, or
    • Criterion 2 or 3 and at least one of criteria 4-7
      1. Completely immobile – i.e., individual cannot make changes in body position without assistance
      2. Limited mobility – i.e., individual cannot independently make changes in body position significant enough to alleviate pressure
      3. Any stage pressure ulcer on the trunk or pelvis
      4. Impaired nutritional status
      5. Fecal or urinary incontinence
      6. Altered sensory perception
      7. Compromised circulatory status

    Group 2 Support Surfaces (as defined in the Definition Section)
    Medically Necessary:
    A group 2 support surface is considered medically necessary if the individual meets:

    • Criteria 1and 2 and 3, or
    • Criterion 4, or
    • Criteria 5 and 6
      1. Multiple stage II pressure ulcers located on the trunk or pelvis
      2. Individual has been on a comprehensive ulcer treatment program (*see below) for at least the past 30 days that has included the use of an appropriate group 1 support surface
      3. The ulcers have worsened or remained the same over the past month
      4. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis
      5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days)
      6. The individual has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

    *The comprehensive ulcer treatment program described above should generally include:

    • Education of the individual and caregiver on the prevention and/or management of pressure ulcers
    • Regular assessment by a nurse, physician or other licensed healthcare practitioner (usually at least weekly for an individual with a stage III or IV ulcer)
    • Appropriate turning and positioning
    • Appropriate wound care (for a stage II, III or IV ulcer)
    • Appropriate management of moisture/incontinence
    • Nutritional assessment and intervention consistent with the overall plan of care

    Continued use of a group 2 support surface is considered medically necessary until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that:

    1. other aspects of the care plan are being modified to promote healing, or
    2. the use of the group 2 support surface is medically necessary for wound management

    When a group 2 pressure reducing support surface is prescribed following a myocutaneous flap or skin graft, continued use is considered medically necessary for up to 60 days from the date of surgery.
    Group 3 Support Surfaces (as defined in the Definition Section)
    Medically Necessary:
    A group 3 support surface (air-fluidized bed) is considered medically necessary if the individual meets all of the following:

    1. The individual has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure sore or is status post muscle/skin flap repair of a stage III or IV pressure sore. An air-fluidized bed is typically needed only 6-12 weeks status-post surgery; and
    2. The individual is bedridden or chair bound as a result of severely limited mobility; and
    3. In the absence of an air-fluidized bed, the individual would require institutionalization; and
    4. The air-fluidized bed is ordered, in writing, by the individual's attending physician based upon a comprehensive assessment and evaluation of the individual after completion of a course of conservative treatment designed to optimize conditions that promote wound healing; and
    5. The course of conservative treatment (*see below) 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; and
    6. A trained adult caregiver is available to assist the individual with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage; and
    7. A physician directs the home treatment regimen and re-evaluates and re-certifies the need for the air-fluidized bed every three months; and
    8. All other alternative equipment has been considered and ruled out.

    *Conservative treatment must include:

    • Frequent repositioning of the individual with particular attention to relief of pressure over bony prominences (usually every two 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.

    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, does not in and of itself affect the medical necessity of an air fluidized bed. Should additional debridement again become necessary while the individual is using an air-fluidized bed (after the first 30-day course of conservative treatment) that will not in and of itself affect the medical necessity of an air-fluidized bed.
    In addition, conservative treatment should generally include:

    • Education of the individual and caregiver on the prevention and management of pressure ulcers
    • Assessment by a physician, nurse or other licensed healthcare practitioner at least weekly
    • Appropriate management of moisture or incontinence

    Continued use of an air-fluidized bed is considered medically necessary until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show that:

    1. other aspects of the care plan are being modified to promote healing; or
    2. the use of the air-fluidized bed is medically necessary for wound management

    Not Medically Necessary:
    A group 1 or group 2 overlay, mattress, or bed is considered not medically necessary when the criteria above are not met.
    A group 3 support surface (air-fluidized bed) is considered not medically necessary under any of the following circumstances:

    1. The individual has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions)
    2. The individual requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material
    3. The caregiver is unwilling or unable to provide the type of care required by the individual on an air-fluidized bed
    4. Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1600 pounds or more)
    5. Electrical system is insufficient for the anticipated increase in energy consumption
    6. Other known contraindications exist

    A support surface (group 1 or group 2) that does not meet the characteristics specified in the Definition section of this document is considered not medically necessary.


    Generally they will pay for rental but not purchase as well, and once your existing pressure ulcer has healed, and you no longer qualify for a Group 2 they will stop paying for it.

    You can find the complete criteria here:

    http://www.anthem.com/medicalpolicie...pw_a053642.htm

    (KLD)

  3. #3
    What I found out is that Medicare has a rent to own policy. When the rental payments reached a set amount they terminated payment to the DME and the bed became mine. Now I am responsible for all repairs, etc.
    You will find a guide to preserving shoulder function @
    http://www.rstce.pitt.edu/RSTCE_Reso...imb_Injury.pdf

    See my personal webpage @
    http://cccforum55.freehostia.com/

  4. #4
    I have BCBS also and they did not have a problem paying for mine, that was after I had a flap surgery.
    C4 incomplete since 1985

  5. #5
    Thanks KLD, that was very informative. I hope my insurance feels I meet the criteria, if not I will have no choice but to pay out of pocket.
    Renee

  6. #6
    Quote Originally Posted by SCIfor55yrs. View Post
    What I found out is that Medicare has a rent to own policy. When the rental payments reached a set amount they terminated payment to the DME and the bed became mine. Now I am responsible for all repairs, etc.
    Thanks 55! My insurance paid for a Rite-Hite Clinitron bed following my surgery in August 2011. I used it until the wound finally healed at the end of December 2012. Insurance paid $2200 a month so they paid around $35,000 to rent it. I was told the bed cost $40,000.

    A lot of people complain about the Clinitron being too hot. Not me, I slept better than ever. It was the first time I actually slept through the night without waking up sweaty and in pain in 20 years. I actually miss the noise too!
    Renee

  7. #7
    Quote Originally Posted by crppled007 View Post
    I have BCBS also and they did not have a problem paying for mine, that was after I had a flap surgery.
    Thanks 007, I hope they pay for one for me too!
    Renee

  8. #8
    I have bcbs and they paid for mine. My surgeon had to request it after my flap surgery. I had lal matress for 6 months and clinic ton bed for 8 weeks. No problems.
    DFW TEXAS- T-10 since March 20th, 1994

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