E0191 — Heel or elbow protector, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Patients using pressure-reducing support surfaces should have a care plan, which has been established by the patient's physician and home care nurse, which is documented in the patient's medical records, and which generally should include the following: Appropriate management of moisture/incontinence; Appropriate turning and positioning; Appropriate wound care (for stage II, III, or IV ulcer); Education of the patient and caregiver on the prevention and/or management of pressure ulcers; Nutritional assessment and intervention consistent with the overall plan; Regular assessment by a nurse, physician, or other licensed healthcare practitioner.
- For group 2: Documentation that the member has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate group 1 support surface (comprehensive treatment components listed in policy).
- For group 2 prescribed for myocutaneous flap or skin graft: documentation of surgery date; continued use generally considered medically necessary for up to 60 days from date of surgery.
Key Coverage Criteria
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Altered sensory perception
- A group 2 support surface is considered medically necessary DME when: The member has multiple stage II (partial thickness skin loss) pressure ulcers located on the trunk or pelvis, AND The member has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate group 1 support surface, AND The member's ulcers have worsened or remained the same over the past month.
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Limited mobility – i.e., member can not independently make changes in body position significant enough to alleviate pressure
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Any stage pressure ulcer on trunk or pelvis
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Fecal or urinary incontinence
- A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Completely immobile – i.e., member can not make changes in body position without assistance.
1 Active Policy
AETNA-CPB-0430 — Pressure Reducing Support Surfaces
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.