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Thread: Bed choices

  1. #11
    Senior Member alan's Avatar
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    What about a sealed stage IV sore, or sores? I've heard once a stage IV, always a stage IV. Does that apply to getting a mattress?
    Alan

    Proofread carefully to see if you any words out.

  2. #12
    Senior Member
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    I was told we had to buy our own mattress. My doctor is fighting it

  3. #13
    Quote Originally Posted by alan View Post
    What about a sealed stage IV sore, or sores? I've heard once a stage IV, always a stage IV. Does that apply to getting a mattress?
    You are right Alan, but unfortunately Medicare (and most other insurances) do not see it that way.

    (KLD)

  4. #14
    Will the dme rent you a bed while you decide? Some equipment that's rented reverts to your ownership after a period of Medicare rental. I have a cough machine under that arrangement.

  5. #15
    "Medicare will not pay for a LAL mattress unless you ALREADY have a stage III or IV pressure ulcer. If that is not the case, then it is likely you would have to private pay for a LAL." (SCI Nurse)

    I already have a low air loss mattress and need a new control unit. I currently do not have any pressure ulcers but have had some bad ones (surgically repaired) and am at high risk. I'm guessing that I'll need to forget about possible reimbursement from Medicare, is the same true for Medicaid? Does this vary from state to state Medicaid?
    1 Corinthians 13:13

  6. #16
    Senior Member
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    Medicade veries from state to state

  7. #17
    I can't speak to the mattress, but Medicare paid for an Invacare 5000IVC (well, the rented it for 13 months and then I owned it).
    And if I lower it down the whole way, I'm practically sitting on the floor.
    I just tested it, and it got down to less than 14" not including mattress height.
    It's served me pretty well, and with my supplemental I didn't pay anything out of pocket.
    That's in Michigan if it makes any difference.

  8. #18
    "Hill Rom Clinitron At Home" rental should be covered, mine was.

  9. #19
    Quote Originally Posted by Blinky1675 View Post
    "Hill Rom Clinitron At Home" rental should be covered, mine was.
    Only if you quality for a Group 3 mattress (not for prevention):

    Indications that are covered for Group I & II mattresses


    Specialty mattresses will be reviewed and coverage is determined according to the medical conditions described below:


    Group I: a mattress overlay or mattress (E0181-E0187, E0196-E0199, and A4640) is eligible for coverage if the following criteria are met and is part of a documented decubitus treatment plan:

    • criterion 1, or
    • criterion 2 or 3 and at least one of criteria 4 through 7.


    1. Completely immobile - i.e. patient cannot make changes in body position without assistance.
    2. Limited mobility i.e. patient 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 II: a powered, mattress overlay or replacement mattress (E0193, E0277, E0371, E0372, E0373) is eligible for coverage if the following criteria are met and are part of a documented decubitus treatment plan:

    • Criterion 1 and 2 and 3, or
    • Criterion 4, or
    • Criterion 5 and 6.


    1. Multiple stage II pressure ulcers located on the trunk or pelvis.
    2. Patient has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate Medicare Group I, (see group I support surface definition) 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 patient has been on a Medicare group II or III support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

    Continued use of a group 2 support surface is covered 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.
    Indications that are not covered

    An Egg Crate Mattress is not covered for those members not enrolled in a hospice program because it is considered household equipment or used for comfort or convenience.

    Definitions

    Specialty mattress replacements and overlays are support surfaces that are either pressure reducing or pressure relief in nature and are designed to cushion bony prominence(s) and areas with high potential for breakdown.

    Group I support surface is defined as a pressure reducing mattress overlay or mattress designed to be placed on top of a standard hospital bed or home mattress which may be non-powered or powered. It can be high density foam; gel, air or water filled, alternating pressure or low air loss. These are identified by Medicare HCPC codes: E0181 - E0187; and E0196 - E0199, and A4640.

    Group II support surface is defined as a powered pressure reducing mattress overlay or replacement mattress (alternating pressure or low air loss). They work by inflating cells or tubes with air. These overlays/mattresses are identified by Medicare HCPC codes: E0193, E0277, E0371, E0372, E0373.

    Group III support surface is an air fluidized bed employing the circulation of filtered air through silicone coated ceramic beads creating the characteristics of fluid. Refer to the DME coverage policy titled Air fluidized specialty bed-group III for coverage criteria. This is identified by Medicare HCPC code: E0194.

    Indications that are covered for Group III mattress

    All of the following must be met to qualify for coverage:

    1. The patient has a Stage 3 (full thickness tissue loss) or Stage 4 (deep tissue destruction) pressure sore.
    2. The patient is bedridden or chair bound as a result of severely limited mobility.
    3. In the absence of an air-fluidized bed, the patient would require institutionalization.
    4. The air-fluidized bed is ordered based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success. The patient must generally have been on the conservative treatment program for at least one month prior to use of the air-fluidized bed with worsening or no improvement of the ulcer. The evaluation generally must be performed within a week prior to initiation of therapy with the air-fluidized bed. Treatment should generally include:
      1. Education of the patient and caregiver on the prevention and/or management of pressure ulcers.
      2. Assessment by a physician, nurse, or other licensed health care practitioner at least weekly.
      3. Appropriate turning and positioning.
      4. Use of a Group 2 support surface, if appropriate.
      5. Appropriate wound care.
      6. Appropriate management of moisture/incontinence.
      7. Nutritional assessment and intervention consistent with the overall plan of care.

    5. A trained adult caregiver is available to assist the patient 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.
    6. A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis.
    7. All other alternative equipment has been considered and ruled out.

    The continued medical necessity of an air fluidized bed must be documented by the treating physician every month. Continued use of an air fluidized bed is covered until the ulcer is healed or, if healing does not continue, there is documentation to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the bed is medically necessary for wound management.

    Indications that are not covered


    1. The patient has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).
    2. The patient 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 a patient on an air-fluidized bed.
    4. Structural support is inadequate to support the weight of the air-fluidized bed system.
    5. Electrical system is insufficient for the anticipated increase in energy consumption.
    6. Other known contraindications exist.

    Definitions

    An air-fluidized bed uses warm air, under pressure, to set silicone coated ceramic beads in motion. This simulates the movement of fluid. When the patient is in this bed, the body weight is evenly distributed over a large surface area. This creates a sensation of floating, aids in the healing of skin pressure sores and helps to prevent further skin breakdown. These beds are a group III pressure reducing support surface and are identified by Medicare HCPC code E0194.
    (KLD)

  10. #20
    Is your CIGNA insurance from your wife's employer, or is it simply a Medicare supplement that you purchased yourself?

    If it is your wife's private insurance, then does it cover some things that Medicare does not? Even if Medicare rejects it, maybe CIGNA will pay for it. I'm assuming you and your doctor called CIGNA to check coverage?

    I have found that fighting with private insurance companies (appeals) can very often work if you are persistent (write good appeal letters, often appeal at least 1-2 times). But fighting with Medicare is nearly impossible. I once fought with Medicare and it took me 1.5 years, and wasn't worth it in the end.

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