Clinical UM Guideline


Subject:  Pressure Reducing Support Surfaces – Groups 1, 2 & 3
Guideline #:  CG-DME-16Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

This document addresses the use of pressure reducing support surfaces. A pressure reducing support surface is designed to prevent or promote the healing of certain types of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site.

A group 1 pressure reducing support surface includes pressure pads for mattresses, non-powered pressure reducing mattresses and powered pressure reducing mattress overlay systems. A group 2 pressure reducing support surface includes powered pressure reducing mattresses, semi-electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays. A Group 3 pressure reducing support surface (e.g., air-fluidized bed) is a device employing the circulation of warm filtered air through small, silicone coated ceramic beads creating the characteristics of fluid. When the individual is placed in the bed, his or her body weight is evenly distributed over a large surface area, which creates the sensation of "floating."

Clinical Indications

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:

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:

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

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:

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:

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.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
 Group 1 support surfaces:
A4640Replacement pad for use with medically necessary alternating pressure pad owned by patient
E0181Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
E0182Pump for alternating pressure pad, for replacement only
E0184Dry pressure mattress
E0185Gel or gel-like pressure pad for mattress, standard mattress length and width
E0186Air pressure mattress
E0187Water pressure mattress
E0188Synthetic sheepskin pad
E0189Lambswool sheepskin pad, any size
E0196Gel pressure mattress
E0197Air pressure pad for mattress, standard mattress length and width
E0198Water pressure pad for mattress, standard mattress length and width
E0199Dry pressure pad for mattress, standard mattress length and width
E0272Mattress, foam rubber
  
 Group 2 support surfaces:
E0193Powered air flotation bed (low air loss therapy)
E0277Powered pressure-reducing air mattress
E0371Non powered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372Powered air overlay for mattress, standard mattress length and width
E0373Non powered advanced pressure reducing mattress
  
 Group 3 support surfaces:
E0194Air fluidized bed
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
Discussion/General Information

Pressure reducing support surfaces are designed to prevent or promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more restricted site. Pressure reducing support surfaces that contain multiple components are categorized according to the clinically predominant component, which is usually the topmost layer of a multi-layer product.

For all types of support surfaces, the support surface provided should be one in which the individual does not "bottom out." Bottoming out is the finding that an outstretched hand, placed palm up between the undersurface of the overlay or mattress and the individual's bony prominence (coccyx or lateral trochanter), can readily palpate the bony prominence. This bottoming out criterion should be tested with the individual 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.

In a meta-analysis by Nicosia and colleagues (2007) the authors concluded data support the use of foam mattresses, air mattresses or overlays versus a standard hospital mattress to reduce the risk of developing heel pressure ulcers. However, the authors noted the results are limited based on the small number and poor quality of controlled clinical trial data included in the meta-analysis. One Cochrane review (McInnes, 2011b) concluded that individuals at high risk for developing pressure ulcers should use higher specification foam mattresses (mattresses which contour to the body) rather than standard hospital foam mattresses. A later Cochrane review (McInnes, 2011a) looked at 18 trials of support surfaces for treatment of pressure ulcers. The authors concluded that "there is no conclusive evidence about the superiority of any support surface for the treatment of existing pressure ulcers" and further studies are required to improve the evidence base about the most effective support surfaces to treat pressure ulcers.

A 2013 literature review by White-Chu and colleagues looked at 14 articles which addressed the prevention of pressure ulcers in individuals with advanced illness. These articles included 1 systematic review, 1 randomized control trial, 3 prospective trials, 2 retrospective cohort trials, 1 cost-effective analysis, 1 quality improvement study, 1 comparative descriptive design trial, and 4 review articles. The systematic review evaluated the use of any support surfaces for the prevention of pressure ulcers and concluded that a higher specification mattress is more likely to prevent pressure ulcers compared to standard hospital mattresses. The randomized controlled trial evaluated frequent positioning as a method to prevent pressure ulcers. This trial did not reach its participant enrollment target. Three prospective trials evaluated different modalities (repositioning, support surfaces, and skin integrity maintenance) for the prevention of pressure ulcers. One of the prospective trials showed the incidence of pressure ulcers was 0% for individuals on a low air loss mattress and 18% for individuals on an integrated power pressure redistribution bed. However, the integrated power pressure redistribution beds were 7 years old and the low air loss beds were brand new. The two retrospective cohort trials evaluated repositioning techniques and risk assessment. One of the retrospective trials found that repositioning every 2 hours did not decrease the incidence of pressure ulcers. The quality improvement study focused on skin integrity and incontinence issues using a barrier product for incontinence, using aqueous cream instead of soap and dermal pads over previous pressure ulcer sites. This study reported a reduction in pressure ulcer prevention from 14% to 1.28% in 6 months. However, this study did not analyze statistical significance. The comparative description design trial looked at 20 participants and the impact of repositioning on blood flow. They reported that blood flow to bony prominences decreased when an individual was in the 30° lateral position as opposed to the supine position. There is limited published literature on the prevention of pressure ulcers in advanced illness and more research is needed to explain how pressure ulcers form in those individuals with advanced illness.

Definitions

Pressure Ulcer (National Pressure Ulcer Advisory Panel, 2007)
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.

Pressure Ulcer Stages

Suspected Deep Tissue Injury:
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate "at risk" persons (a heralding sign of risk).

Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.*This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

*Bruising indicates suspected deep tissue injury

Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV:
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable:
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

Support Surface Descriptions/Definitions   

Group 1

Group 1 pressure reducing support surfaces include: pressure pads for mattresses, non-powered pressure reducing mattresses and powered pressure reducing mattress overlay systems.

Pressure pads for mattresses describe non-powered pressure reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress. This includes:

Non-powered pressure reducing mattresses include:

Powered pressure reducing mattress overlay systems (alternating pressure or low air loss) are characterized by all of the following:

  1. An air pump or blower that provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay
  2. Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater
  3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate member lift, reduce pressure, and prevent bottoming out

Group 2

Group 2 pressure reducing support surfaces include: powered pressure reducing mattresses, semi-electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays, advanced non-powered pressure reducing mattresses and advanced non-powered pressure reducing mattress overlays.

A powered pressure reducing mattress (alternating pressure, low air loss, or powered flotation without low air loss) is characterized by all of the following:

A semi-electric hospital bed with a fully integrated powered pressure reducing mattress that has all the characteristics defined above is considered a group 2 pressure reducing support surface.

An advanced non-powered pressure reducing mattress overlay is characterized by all of the following:

A powered pressure reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) is characterized by all of the following:

An advanced non-powered pressure reducing mattress is characterized by all of the following:

Pressure reducing support surfaces that contain multiple components are categorized according to the clinically predominant component, which is usually the topmost layer of a multi-layer product. For example, a product with 3-inch powered air cells on top of a 3-inch foam base would be categorized as a powered overlay not as a powered mattress.

Group 3

Group 3 pressure reducing support surfaces include air-fluidized beds. An air-fluidized bed uses the circulation of warm filtered air through small, silicone coated ceramic beads creating the characteristics of fluid. When the individual is placed in the bed, his/her body weight is evenly distributed over a large surface area, which creates the sensation of "floating."

The Centers for Medicare and Medicaid (CMS) criteria were utilized in the development of this document.

References

Peer Reviewed Publications:

  1. Garcia AD, Thomas DR. Assessment and management of chronic pressure ulcers in the elderly. Med Clin North Am. 2006; 90(5):925-944.
  2. Nicosia G, Gliatta AE, Woodbury MG, Houghton PE. The effect of pressure-relieving surfaces on the prevention of heel ulcers in a variety of settings: a meta-analysis. Int Wound J. 2007; 4(3):197-207.
  3. White-Chu EF, Reddy M. Pressure ulcer prevention in patients with advanced illness. Curr Opin Support Palliat Care. 2013; 7(1):111-115.

 Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services. National Coverage Determinations (NCD). Available at: http://www.cms.gov/MCD/index_list.asp?list_type=ncd. Accessed on August 6, 2013.
    • Air-Fluidized Bed. NCD #280.8. Effective November 1, 2000.
    • Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005
  2. CGS Administrators LLC. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=P&num_on_page=25&page_num=1. Accessed on September 3, 2013.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 1 (L11563). Updated 03/22/2013.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 2 (L11564). Updated 03/08/2013.
  3. McInnes E, Dumville JC, Jammali-Blasi A, Bell-Syer SEM. Support surfaces for treating pressure ulcers. Cochrane Database Syst Rev. 2011a(12):CD009490.
  4. McInnes E, Jammali-Blasi A, Bell-Syer SEM, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011b(4):CD001735.
  5. National Pressure Ulcer Advisory Panel. Pressure ulcer staging system. Revised February 2007. Available at: http://www.npuap.org/. Accessed on August 6, 2013.
  6. NHIC, Corp. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=P&num_on_page=25&page_num=1. Accessed on September 3, 2013.
  7. Noridian Administrative Services. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=P&num_on_page=25&page_num=1. Accessed on September 3, 2013.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 1 (L11578). Updated 03/24/2013.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 2 (L11579). Updated 03/10/2013.
Index

Air-Fluidized Bed
Clinitron®
Fluid Air
Mediscus Heavy Duty System
Pressure Reducing Support Surfaces-Group 1
Pressure Reducing Support Surfaces-Group 2
Pressure Reducing Support Surfaces-Group 3

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion/General Information and References.
Reviewed11/08/2012MPTAC review. Updated Discussion/General Information and References.
Reviewed11/17/2011MPTAC review. Updated Coding, Discussion/General Information and References.
Reviewed11/18/2010MPTAC review. References updated.
Revised11/19/2009MPTAC review. Removed Place of Service section. Updated Coding and References. Title change to Pressure Reducing Support Surfaces – Groups 1, 2 & 3. Merged CG-DME-17 into CG-DME-16.
Reviewed11/20/2008MPTAC review. References, Coding, Discussion/General Information section and Definitions updated.
Reviewed11/29/2007MPTAC review. Updated information on the definition and staging of pressure ulcers in the Definition section. References updated.
Reviewed12/07/2006MPTAC review. References and coding updated.
 01/01/2007Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS E0180 deleted 12/31/2006.
New12/01/2005MPTAC initial document development.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 No Document
Anthem CO/NV

10/29/2004

DME.212Pressure Reducing Support Surfaces-Group I
Anthem CO/NV

10/29/2004

DME.213Pressure Reducing Support Surfaces-Group II
Anthem MW

11/05/2004

DME-011Pressure Reducing Support Surfaces: Group 2
Anthem CT

10/01/2004

DME Coverage Criteria Guideline, Section FPressure Reducing Surfaces
WellPoint Health Networks, Inc.

 

 No Document