CSHCN 2009 > Durable Medical Equipment (DME) > Benefits, Limitations, and Authorization Requirements

17.3.8.1 Authorization and Prior Authorization Requirements

To request authorization for manual or electric hospital beds, the provider must submit documentation of medical necessity and a completed "CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME)" form. The form is available in Appendix B, "Forms," on page B-1.

The following documentation must be included with the request for authorization or with the first claim:

•Client's diagnosis

•Client's age

•Client's height and weight

•Limitations of the caregiver

•Explanation addressing why a standard bed or crib will not meet the client's needs

Electric hospital beds may be considered for prior authorization as a purchase (long-term use) or as a rental (short-term use) if any of the following conditions exist:

•Client is able to assist with his or her personal care and can physically operate the controls

•Caregiver is physically limited and cannot crank a manual bed

•Caregiver needs to be able to adjust the bed quickly to assist with the client's personal care

All requests for the purchase of an electric hospital bed with or without a mattress require medical review.

The following procedure codes must be used to request authorization and to submit claims for reimbursement of rental or purchase of equipment:

The purchase of a hospital bed without a mattress may be considered for reimbursement only if a custom mattress or bed positioning system is also authorized due to medical necessity.