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24.5.23.1 Criteria for Grouping Levels
Group 1 Support Surfaces
A group 1 Support Surface may be considered if the client is completely immobile without assistance, or either of the following first two criteria:
• The client has limited mobility, or
•The client has an existing pressure ulcer on the pelvis or trunk, and
And at least one of these four criteria:
•Impaired nutritional status
•Fecal or urinary incontinence
•Altered sensory perception
•Compromised circulatory status
Each of the support surfaces described below are considered a benefit of the Home Health Services Program when medical necessity criteria for Group 1 support surfaces are met.
Pressure pads for mattresses/nonpowered pressure-reducing mattress overlays are designed to be placed on top of a standard hospital or home mattress. Pressure pads/nonpowered pressure-reducing mattress overlays for mattresses with the following features may be considered for reimbursement with documentation of medically necessity:
•A gel or gel-like layer with a height of two inches or greater.
•An air mattress overlay with interconnected air cells that are inflated with an air pump and a cell height of three inches or greater.
•A water mattress overlay with a filled height of three inches or greater.
•A foam mattress overlay with all the following features:
•Base thickness of two inches or greater and peak height of three inches or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least three inches if it is a nonconvoluted overlay.
•Foam with a density and other qualities that provide adequate pressure reduction.
•Durable, waterproof cover.
Nonpowered pressure-reducing mattresses are designed to be placed directly on a hospital bed frame. Nonpowered pressure-reducing mattresses, with the following features, may be considered for reimbursement with documentation supporting medical necessity:
•A foam mattress with all the following features may be considered with documentation supporting medical necessity. Documentation must include all of the following features:
•A foam height of five inches or greater.
•Foam with a density and other qualities that provide adequate pressure reduction.
•Durable, waterproof cover.
•Can be placed directly on a hospital bed frame.
•An air, water or gel mattress with all the following features may be considered for reimbursement:
•A height of five inches or greater.
•Durable, waterproof cover.
Powered pressure-reducing mattress overlay systems (alternating pressure or low air loss) are designed to be placed on top of a standard hospital or home mattress. A powered pressure reducing mattress overlay system, with all the following features, may be considered for reimbursement when documentation supports medical necessity:
•The system includes an air pump or blower which provides either sequential inflation and deflation of air cells, or a low interface pressure throughout the overlay.
•Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater.
•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 client lift, reduces pressure, and prevents bottoming out.
•The manufacturer's product information substantiates that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces.
Group 2 Support Surfaces
A Group 2 support surface may be considered if the client has multiple stage II ulcers on the trunk or pelvis and has been on a comprehensive ulcer treatment program for at least the past month which has included the use of a Group 1 support surface.
The client must also have at least one of the following:
•The ulcers have remained the same or worsened over the past month.
•There are large or multiple stage III or IV pressure ulcers on the trunk or pelvis.
•A myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the last 60 days, and have been on a Group 2 or 3 support surface immediately before discharge from the hospital or a nursing facility (discharge within the past 30 days).
Each of the support surfaces described below are considered a benefit of the Home Health Services Program when medical necessity criteria for Group 2 support surfaces are met.
Powered pressure-reducing mattress (alternating pressure low air loss, or powered flotation without air loss) is designed to be placed directly on a hospital bed frame. This device with all the following features may be considered for reimbursement when documentation supports medical necessity:
•The system includes an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress.
•Inflated cell height of the air cells through which air is being circulated is five inches or greater.
•Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattress), and air pressure to provide adequate client lift, reduce pressure, and prevent bottoming out.
•A surface designed to reduce friction and shear.
A semi-electric hospital bed with fully integrated powered pressure-reducing mattress that has all of the features described above may be considered for reimbursement when documentation supports medical necessity.
An advanced nonpowered pressure-reducing mattress overlay is designed to be placed on top of a standard hospital or home mattress. This device, with all the following features, may be considered for reimbursement when documentation supports medical necessity.
•Height and design of individual cells which provide significantly more pressure reduction than Group 1 overlay and prevent bottoming out.
•Total height of 3 inches or greater.
•A surface designed to reduce friction and shear.
•The manufacture product information substantiates that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces.
A powered pressure-reducing mattress overlay (low air loss, powered flotation without low air loss, or alternating pressure) is designed to be placed on top of a standard hospital or home mattress designed to reduce friction and shear. This device, with all the following features, may be considered for reimbursement when documentation supports medical necessity:
•The system includes an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay.
•Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater.
•Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure to provide adequate client lift, reduce pressure and prevent bottoming out.
An advanced nonpowered pressure-reducing mattress is designed to be placed directly on a hospital bed frame. This device with all the following features may be considered for reimbursement when documentation supports medical necessity:
•Height and design of individual cells which provide significantly more pressure than a Group 1 mattress and prevent bottoming out.
•Total height of five inches or greater.
•A surface designed to reduce friction and shear.
•Documented evidence substantiates that the product is effective for the treatment of conditions described by the coverage criteria for Group 2 support surfaces.
Sheepskin and lambs wool pads are considered a benefit of the Home Health Services Program under the same conditions as alternating pressure pads and mattresses (Group 2 pressure-reducing support surfaces).
Group 3 Support Surfaces
A Group 3 support surface may be considered if all the following criteria are met:
•Presence of a stage III or IV ulcer.
•Severely limited mobility rendering the client bed or chair bound.
•Without an air-fluidized bed, the client would be institutionalized.
•The client has been placed on a Group 2 support surface for at least a month before ordering the air-fluidized bed with the ulcer(s) not improving or worsening.
•There has been at least weekly assessment of the wound by the physician, a nurse or other licensed health-care professional and the treating physician has done a comprehensive evaluation of the client's condition within the week before ordering the air-fluidized bed.
•A trained adult caregiver is available to assist the client with activities of daily living, maintaining fluid balance, supplying dietary needs, aiding in repositioning and skin care, administering prescribed treatments, recognizing and managing altered mental status, and managing the air-fluidized bed system and its potential problems, such as leakage.
•The physician continues to reevaluate and direct the home treatment regimen monthly.
•All other alternative equipment has been considered and ruled out.
The existence of any one of the following conditions may result in noncoverage of the air-fluidized bed:
•Coexisting pulmonary disease (the lack of firm back support can render coughing ineffective and dry air inhalation thickens pulmonary secretions).
•Wounds requiring moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material (if wet-to-dry dressings are being utilized, dressing changes must be frequent enough to maintain their effectiveness).
•For clients 21 years of age and older, the caregiver is unwilling or unable to provide the type of care required by the client on an air-fluidized bed.
•The home's structural support or electrical system cannot safely accommodate the air-fluidized bed.
The groups for pressure-reducing support surfaces used in this policy are defined as follows.
Initial prior authorization for a Group 3 pressure-reducing support surface will be for no more than 30 days. Prior authorized extensions may be considered for reimbursement in increments of 30-day periods, up to a maximum of four months, when documentation supports continued significant improvement in wound healing. Coverage beyond four months will be on a case-by-case basis after review by the medical director or designee.
An air-fluidized bed uses warm air under pressure to set small ceramic beads in motion, which simulate the movement of fluid. When the client is placed in the bed, the client's body weight is evenly distributed over a large surface area, which creates the sensation of floating. Air-fluidized beds may be considered for reimbursement when the medical necessity criteria for Group 3 support surfaces are met.
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