Clinical UM Guideline

This document addresses the use of hospital beds, a specialty bed used primarily in the treatment of individuals with an illness or injury. Hospital bed accessories are durable medical equipment items used in conjunction with a hospital bed.

Note: Please see the following related document for additional information:

• CG-DME-16 Pressure-Reducing Support Surfaces

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

A.  Hospital Beds

Medically Necessary: 

A fixed height hospital bed is considered medically necessary if one or more of the following criteria are met:

1. The individual has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain, prevent contractures, promote good body alignment or avoid respiratory infections; or
2. The individual 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. Pillows or wedges must have been considered and ruled out. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed; or
3. The individual requires special attachments, such as traction equipment, that can only be attached to a hospital bed.

A variable height hospital bed is considered medically necessary if the individual meets one or more 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. This includes, but is not limited to:

1. Severe arthritis;
2. Fractured hips or other lower extremity injuries;
3. Spinal cord injuries;
4. Severe cardiac conditions;
5. Stroke.

A semi-electric hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height bed and either of the following:

1. Requires frequent changes in body position; or
2. Has an immediate need for a change in body position.

A heavy-duty, extra-wide hospital bed is considered medically necessary if the individual meets one or more of the criteria for a fixed height hospital bed and the individual’s weight is more than 350 pounds, but does not exceed 600 pounds.

An extra heavy-duty hospital bed is considered medically necessary if the individual meets one or more of the criteria for a hospital bed and the individual’s weight exceeds 600 pounds.

An enclosed crib or enclosed bed is considered medically necessary if the individual needs to be restrained to bed, for example individuals with seizures, disorientation, vertigo, and neurological disorders including autism spectrum disorder. Clinical documentation must be provided that states less invasive strategies (that is, bed rails, bed rail protectors, or environmental modifications) have been tried and have not been successful.

A request for a hospital grade, pediatric crib will be reviewed for medical necessity on an individual basis.

Not Medically Necessary:

A hospital bed is considered not medically necessary when the above criteria have not been met.

A total electric hospital bed is considered not medically necessary. The height adjustment feature is considered to be a convenience feature.

Ordinary (Non-Hospital) beds are considered not medically necessary. An ordinary bed does not meet the definition of durable medical equipment as it is not primarily medical in nature and is not primarily used in the treatment of a disease or injury.

Power or manual lounge beds are considered not medically necessary since they are not primarily medical in nature and are considered to be a comfort or convenience item.

B.  Bed Accessories

Medically Necessary:

Trapeze equipment is considered medically necessary when the individual meets the following criteria:

1. Is confined to bed; and
2. Needs this device to sit up because of any of the following:
   1. A respiratory condition, or
   2. To change body position for other medical reasons; or
   3. To get in or out of bed.

Heavy duty trapeze equipment is considered medically necessary if the individual meets the criteria for regular trapeze equipment and weighs more than 250 pounds.

A bed cradle is considered medically necessary when it is necessary to prevent contact with the bed coverings. This includes, but is not limited to individuals with burns, decubitus or diabetic ulcers, or gouty arthritis.

Side rails or safety enclosures (such as, frame/canopy) are considered medically necessary when they are required by the individual’s condition and they are an integral part of, or an accessory to, a hospital bed.

If an individual’s condition requires a replacement innerspring mattress or foam rubber mattress it will be considered medically necessary for an individual-owned hospital bed.

Not Medically Necessary:

The following bed accessories are considered not medically necessary since they are not primarily medical in nature, are not mainly used in the treatment of a disease or injury and are normally of use to people who do not have a disease or injury:

1. Bedboards;
2. Overbed table;
3. Bed baths, bed spectacles, bed trays/reading tables, call switches, foot boards, bed lapboards;
4. Side rails when requested with a non-hospital or ordinary bed.

Side rails or frame/canopy for use with a hospital bed are considered not medically necessary when the above criteria are not met.

This document describes clinical studies and expert recommendations, and explains when the use of hospital beds and accessories are appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

Hospital beds and accessories may be considered appropriate medical equipment for people with health conditions or injuries that limit movement or require special care. These include beds that have a fixed or variable height, semi-electric beds, and heavy-duty beds. Hospital beds support body positioning, transfers, or the use of attached devices. Enclosed beds or cribs may be covered in specific cases where safety is a major concern. However, some beds, such as total electric models and furniture-style beds, are not considered medical equipment. These are viewed as comfort items. Accessories, such as trapeze bars to hold on to and assist in repositioning or side rails to prevent falls, may be medically necessary if they help with movement or safety. Other items such as overbed tables and lounge beds are not covered because they are not used for medical care.

What the Studies Show

Hospital beds that adjust for positioning can improve comfort, prevent health issues such as breathing problems or skin ulcers, and help with recovery. For example, people with heart failure or breathing conditions may need the head of the bed raised more than 30 degrees. People with serious injuries or conditions, including stroke, arthritis, or spinal cord injury may benefit from beds that adjust in height to help with getting in or out. Some people also need beds that support equipment like traction devices. Enclosed beds have been shown to reduce risks for people with seizures or autism who may wander at night. However, not all enclosed beds are safe. The Vail Enclosure Bed was removed from the market after the U.S. Food and Drug Administration (FDA) found it posed a serious risk of injury or death due to suffocation.

What is Clinically Appropriate?

What is Not Clinically Appropriate?

The following have not been proven to improve health and are not considered clinically appropriate:

• Total electric hospital beds: Height adjustment is considered a comfort feature, not a medical need.
• Ordinary or lounge beds: These are not designed for medical use and are considered furniture.
• Non-medical accessories: Items such as bed trays, overbed tables, footboards, or lapboards are not used to treat health conditions.
• Side rails with non-hospital beds: These are not part of durable medical equipment.
• Hospital bed side rails or enclosures: Not appropriate unless medical criteria are met.

(Return to Desription)

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.

Hospital beds
When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Accessories
When services may be Medically Necessary when criteria are met:

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

Summary

This document outlines the medical necessity criteria for hospital beds and related accessories used in treating individuals with illnesses or injuries. Types of hospital beds addressed in this guideline include fixed height, variable height, semi-electric, and heavy-duty models. This guideline details when various types of beds are considered medically necessary based on an individual’s condition (for example, the need for specific body positioning, transfer assistance, or specialized attachments). It also specifies that total electric and ordinary beds are not medically necessary, as they are considered comfort or convenience items rather than medical equipment. Bed accessories such as trapeze bars, bed cradles, and side rails are covered when they support essential medical needs, while non-medical items including overbed tables and lounge beds are excluded. The document further discusses the use of enclosed beds for individuals requiring restraint due to conditions such as seizures or autism spectrum disorder, emphasizing safety concerns.

Discussion

Descriptions

A fixed height hospital bed is one with manual head and leg elevation adjustments but no height adjustment.

A variable height hospital bed is one with manual height adjustment and with manual head and leg elevation adjustments.

A semi-electric bed is one with manual height adjustment and with electric head and leg elevation adjustments.

A total electric bed is one with electric height adjustment and with electric head and leg elevation adjustments.

An ordinary bed is one that is typically sold as furniture. It consists of a frame, box springs and mattress. It is a fixed height and has no head or leg elevation adjustments. It is normally for use in the absence of illness or injury.

Power or manual lounge beds, like other ordinary beds, are typically sold as furniture and are not considered durable medical equipment as they are used in the absence of illness or injury. The following are examples of lounge beds:

1. Craftmatic^® Adjustable Bed;
2. Adjust-A-Sleep Adjustable Bed;
3. Electropedic^® Adjustable Bed (Electropedic Beds, Burbank, CA);
4. Simmons^® Beautyrest^® Adjustable Bed (Simmons Bedding Company, Norcross, GA);
5. Adjustable, vibrating beds.

The U.S. Food and Drug Administration (FDA) in 2005 determined that the Vail Enclosure Bed poses a significant public health risk because individuals can become entrapped and suffocate, resulting in severe neurological damage or death. Vail Products, Inc of Toledo, Ohio, has permanently ceased manufacture, sale and distribution of all Vail enclosed bed systems.

Autism spectrum disorder (ASD) is a neurological and developmental disorder that affects communication, learning and behavior (National Institute of Mental Health, 2022). Individuals with ASD are at risk of placing themselves in danger by “wandering” or “eloping” (leaving a supervised, safe space). Elopement may be a significant contributor to mortality in individuals with ASD due to accidents, such as suffocation and drowning. A study by Anderson and colleagues (2012) of 1218 families of children with AЅD found that approximately one-half of these children had tried to elope at least once after four years of age. Night wandering is a special concern, and among parents of elopers, 43% reported the issue had prevented family members from getting a good night's sleep. An enclosed bed may provide a safe and secure environment at night to prevent wandering.

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

Peer Reviewed Publications:

1. Anderson C, Law JK, Daniels A, et al. Occurrence and family impact of elopement in children with autism spectrum disorders. Pediatrics. 2012; 130(5):870-877.
2. Hampton S. Can electric beds aid pressure sore prevention in hospitals? Br J Nurs. 1998; 7(17):1010-1017.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Medicare and Medicaid Services. National Coverage Determination. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on February 13, 2026.
   • Durable Medical Equipment Reference List. NCD #280.1. Effective June 9, 2025.
   • Hospital Beds. NCD #280.7. This is a longstanding national coverage determination. The effective date of this version has not been posted.
2. CGS Administrators, LLC. Jurisdiction D. Local Coverage Determination for Hospital Beds and Accessories (L33820). Revised 1/1/2020. Available at: https://www.cms.gov/medicare-coverage-database/search.aspx. Accessed on February 13, 2026.
3. National Institute of Mental Health. Autism Spectrum Disorder. Revised 2025. Available at: https://www.nimh.nih.gov/health/publications/autism-spectrum-disorder. Accessed on February 13, 2026.
4. U.S. Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH). Medical Devices. Hospital beds. Updated August 23, 2018. Available at: http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/HospitalBeds/default.htm. Accessed on February 13, 2026.

Hospital Beds and Accessories
Safe Place Bedding

Federal and State law, as well as contract language, and Coverage Guidelines take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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