E0196 — Gel pressure mattress
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 claim submission for items covered by this policy.
- For DMEPOS base items requiring Written Order Prior to Delivery (WOPD), the supplier must receive a signed SWO/WOPD before delivering the item to the beneficiary.
- For base items requiring WOPD, the WOPD must list the base item and may list separately billed associated options/accessories/supplies prior to delivery; the signed WOPD must be on file before billing associated items.
- Suppliers must maintain proof of delivery (POD) documentation in their files and make POD available to the Medicare contractor upon request.
Key Coverage Criteria
- A Group 1 mattress overlay or mattress (HCPCS: E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199, A4640) is covered when the beneficiary is completely immobile (cannot make changes in body position without assistance).
- A Group 1 mattress overlay or mattress (same HCPCS list) is covered when the beneficiary has limited mobility (cannot independently change position enough to alleviate pressure) AND at least one of: impaired nutritional status; fecal or urinary incontinence; altered sensory perception; or compromised circulatory status.
- A Group 1 mattress overlay or mattress (same HCPCS list) is covered when the beneficiary has any stage pressure ulcer on the trunk or pelvis AND at least one of: impaired nutritional status; fecal or urinary incontinence; altered sensory perception; or compromised circulatory status.
- The provided support surface must not 'bottom out' when tested by palpation at the beneficiary's coccyx or lateral trochanter in supine (head flat), supine (head elevated ≤30°), and side-lying positions.
- 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.
4 Active Policies
L33830 — Pressure Reducing Support Surfaces - Group 1
J19
DME101.001 — Hospital Beds and Related Equipment
AETNA-CPB-0430 — Pressure Reducing Support Surfaces
ANTHEM-CG-DME-16 — CG-DME-16 Pressure-Reducing Support Surfaces
Related Codes
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