For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.
In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:
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The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
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Refer to the Supplier Manual for additional information on documentation requirements.
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Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.
For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
An air-fluidized bed is covered only if all of the following criteria are met:
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The beneficiary has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure ulcer (Refer to the ICD-10 codes in the LCD-related Policy Article for applicable diagnoses).
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The beneficiary is bedridden or chair bound as a result of severely limited mobility.
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In the absence of an air-fluidized bed, the beneficiary would require institutionalization.
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The air-fluidized bed is ordered in writing by the beneficiary’s treating practitioner based upon a comprehensive assessment and evaluation of the beneficiary after completion of a course of conservative treatment designed to optimize conditions that promote wound healing. The evaluation generally must be performed within one month prior to initiation of therapy with the air-fluidized bed.
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The course of conservative treatment 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. Conservative treatment must include:
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Frequent repositioning of the beneficiary with particular attention to relief of pressure over bony prominences (usually every 2 hours); and
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Use of a Group 2 support surface to reduce pressure and shear forces on healing ulcers and to prevent new ulcer formation; and
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Necessary treatment to resolve any wound infection; and
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Optimization of nutrition status to promote wound healing; and
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Debridement by any means, including wet-to-dry gauze dressings, to remove devitalized tissue from the wound bed; and
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Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.
In addition, conservative treatment should generally include:
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Education of the beneficiary and caregiver on the prevention and management of pressure ulcers; and
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Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly, and
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Appropriate management of moisture/incontinence.
An occlusive barrier is required, when necessary, to maintain a moist wound-healing environment that may otherwise be compromised by the drying action of airflow generated by air-fluidized therapy. If moist dressings are NOT required because of the wound characteristics (e.g. heavily exudative wound, etc.), the occlusive barrier is not required as a condition for reimbursement.
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 will not preclude coverage of an air-fluidized bed. Should additional debridement again become necessary while a beneficiary is using an air-fluidized bed (after the first 30-day course of conservative treatment) that will not cause the air-fluidized bed to be denied.
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A trained adult caregiver is available to assist the beneficiary 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.
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A treating practitioner directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis.
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All other alternative equipment has been considered and ruled out.
An air-fluidized bed will be denied as not reasonable and necessary under any of the following circumstances:
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The beneficiary has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions);
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The beneficiary 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;
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The caregiver is unwilling or unable to provide the type of care required by the beneficiary on an air-fluidized bed;
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Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1600 pounds or more);
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Electrical system is insufficient for the anticipated increase in energy consumption; or
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Other known contraindications exist.
Payment is not included for the caregiver or for architectural adjustments such as electrical or structural improvement.
The continued coverage of an air-fluidized bed as reasonable and necessary must be documented by the treating practitioner every month. Continued use of an air fluidized bed is covered until the ulcer is healed or, if healing does not continue, there is documentation to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the bed is reasonable and necessary for wound management.
If the stated coverage criteria for an air-fluidized bed are not met, the claim will be denied as not reasonable and necessary.
GENERAL
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.
For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.
