Clinical UM Guideline

 

Subject: Pressure Reducing Support Surfaces – Groups 1, 2 & 3
Guideline #:  CG-DME-16 Publish Date:    10/17/2018
Status: Reviewed Last Review Date:    09/13/2018

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.

Clinical Indications

Group 1 Support Surfaces (as defined in the Definition Section)

Medically Necessary:

Use of a group 1 mattress overlay or mattress is considered medically necessary if the individual meets:

  1. Criterion 1, or
  2. Criterion 2 or 3 and at least one of criteria 4-7
    1. Completely immobile – that is, individual cannot make changes in body position without assistance
    2. Limited mobility – that is, individual 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 2 Support Surfaces (as defined in the Definition Section)

Medically Necessary:

Use of a group 2 support surface is considered medically necessary if the individual meets:

  1. Criteria 1 and 2 and 3, or
  2. Criterion 4, or
  3. Criteria 5 and 6
    1. Multiple stage II pressure ulcers located on the trunk or pelvis
    2. Individual has been on a comprehensive ulcer treatment program (*see below) for at least the past 30 days that has included the use of an appropriate group 1 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 individual has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days)

*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:

Use of 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: 

Use of a group 1 or group 2 overlay, mattress, or bed is considered not medically necessary when the criteria above are not met.

Use of 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

Use of 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:

A4640

Replacement pad for use with medically necessary alternating pressure pad owned by patient

E0181

Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty

E0182

Pump for alternating pressure pad, for replacement only

E0184

Dry pressure mattress

E0185

Gel or gel-like pressure pad for mattress, standard mattress length and width

E0186

Air pressure mattress

E0187

Water pressure mattress

E0188

Synthetic sheepskin pad

E0189

Lambswool sheepskin pad, any size

E0196

Gel pressure mattress

E0197

Air pressure pad for mattress, standard mattress length and width

E0198

Water pressure pad for mattress, standard mattress length and width

E0199

Dry pressure pad for mattress, standard mattress length and width

E0272

Mattress, foam rubber

 

 

 

Group 2 support surfaces:

E0193

Powered air flotation bed (low air loss therapy)

E0277

Powered pressure-reducing air mattress

E0371

Non powered advanced pressure reducing overlay for mattress, standard mattress length and width

E0372

Powered air overlay for mattress, standard mattress length and width

E0373

Non powered advanced pressure reducing mattress

 

 

 

Group 3 support surfaces:

E0194

Air fluidized bed

 

 

ICD-10 Diagnosis

 

 

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.

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.”

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 one systematic review, one randomized control trial, three prospective trials, two retrospective cohort trials, one cost-effective analysis, one quality improvement study, one comparative descriptive design trial, and four 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 Injury Ulcer (National Pressure Ulcer Advisory Panel, 2016)
A pressure injury is localized damage to the skin and underlying tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, com-morbidities and condition of the soft tissue.

Pressure Injury Stages

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

Stage 3 Pressure Injury: Full-thickness skin loss
Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Stage 4 Pressure Injury: Full-thickness skin and tissue loss
Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.  If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration
Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.  This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.  The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

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:

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 Services (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. Shi C, Dumville JC, Cullum N. Support surfaces for pressure ulcer prevention: A network meta-analysis. PLoS One. 2018; 13(2):e0192707.
  4. 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 22, 2018.
    • 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 August 22, 2018.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 1 (L33830). Updated 01/01/2017.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 2 (L33642). Updated 05/25/2017.
    • Local Coverage Determination for Pressure Reducing Support Surfaces – Group 3 (L33692). Updated 01/01/2017
  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 Injury Stages. Revised 2016. Available at: http://www.npuap.org/. Accessed on August 22, 2018.
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

Status

Date

Action

Reviewed

09/13/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.

Reviewed

11/02/2017

MPTAC review. Updated References section. The document header wording updated from “Current Effective Date” to “Publish Date.”

Revised

11/03/2016

MPTAC review. Updated formatting in Clinical Indications section. Made minor language revisions to clinical indications for clarification. Updated Definitions and Reference sections.

Revised

11/05/2015

MPTAC review. Updated Description/Scope, Background/Overview, and References. Removed ICD-9 codes from Coding section.

Reviewed

11/13/2014

MPTAC review. Updated References.

Reviewed

11/14/2013

MPTAC review. Updated Discussion/General Information and References.

Reviewed

11/08/2012

MPTAC review. Updated Discussion/General Information and References.

Reviewed

11/17/2011

MPTAC review. Updated Coding, Discussion/General Information and References.

Reviewed

11/18/2010

MPTAC review. References updated.

Revised

11/19/2009

MPTAC 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.

Reviewed

11/20/2008

MPTAC review. References, Coding, Discussion/General Information section and Definitions updated.

Reviewed

11/29/2007

MPTAC review. Updated information on the definition and staging of pressure ulcers in the Definition section. References updated.

Reviewed

12/07/2006

MPTAC review. References and coding updated.

 

01/01/2007

Updated coding section with 01/01/2007 CPT/HCPCS changes; removed HCPCS E0180 deleted 12/31/2006.

New

12/01/2005

MPTAC initial document development.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

No Document

Anthem CO/NV

10/29/2004

DME.212

Pressure Reducing Support Surfaces-Group I

 

Anthem CO/NV

10/29/2004

DME.213

Pressure Reducing Support Surfaces-Group II

 

Anthem MW

11/05/2004

DME-011

Pressure Reducing Support Surfaces: Group 2

 

Anthem CT

10/01/2004

DME Coverage Criteria Guideline, Section F

Pressure Reducing Surfaces

WellPoint Health Networks, Inc.

 

 

No Document