E0194, Air fluidized bed
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; claims submitted without a completed SWO shall be denied.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed WOPD before delivery; delivery without a WOPD will result in denial.
- When a WOPD is required and there are separately billed associated options/accessories/supplies, the WOPD must list the base item and may list the separately billed associated items prior to delivery.
- The comprehensive assessment/evaluation and documentation that a one-month course of conservative treatment was performed without progression toward healing must be available (institution records acceptable to verify conservative treatment).
Key Coverage Criteria
- Beneficiary has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure ulcer.
- Beneficiary is bedridden or chair-bound as a result of severely limited mobility.
- In the absence of an air-fluidized bed, the beneficiary would require institutionalization.
- Air-fluidized bed is ordered in writing by the treating practitioner based on a comprehensive assessment and evaluation after completion of a course of conservative treatment.
- Comprehensive evaluation generally must be performed within one month prior to initiation of air-fluidized bed therapy.
- A course of conservative treatment of at least one month duration without progression toward wound healing is required prior to ordering an air-fluidized bed.
10 Active Policies
DME101.001, Hospital Beds and Related Equipment
ANTHEM-CG-DME-16, CG-DME-16 Pressure-Reducing Support Surfaces
L33692, Pressure Reducing Support Surfaces - Group 3
UHC-POL-beds-mattresses, Beds and Mattresses
BCBSIL-DME101.001, Hospital Beds and Related Equipment
Related Codes
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