E0300 — Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage (refer to the protocol titled Medical Records Documentation Used for Reviews).
- Documentation of the qualifying diagnosis (e.g., diagnosis related to cognitive impairment such as traumatic brain injury, cerebral palsy, seizure disorder, or a severe behavioral disorder) that necessitates the equipment.
- Documentation that medications to address seizures and/or disruptive or harmful behaviors have been optimized or are not appropriate.
- Documentation of the specific safety risk(s) that justify use of a safety enclosure (examples listed: claustrophobia; high risk of falls due to a clinical condition; uncontrolled movements; violent or self-destructive behaviors such as uncontrolled head banging).
Key Coverage Criteria
- Hospital beds and accessories are proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Durable Medical Equipment: Support Surfaces; Hospital Beds, Cribs, and Accessories.
- Support surfaces (mattress overlays, mattresses, specialty beds) for individuals at risk for skin breakdown (preventive support surfaces).
- Therapeutic support surfaces for individuals with advanced pressure injuries (i.e., stage 3, stage 4, or unstageable pressure injuries).
- Specialty beds designed to keep individuals with altered self-awareness and/or neurologic impairments from falling out of bed or suffering an injury (promote safety while asleep and while awake and moving around).
- Safety enclosure with beds (e.g., pediatric enclosed bed, adult bed, safety enclosure) are covered as DME for individuals that have a risk for safety in bed when ALL of the following criteria are met: 1) Use of equipment is required due to a diagnosis related to cognitive impairment (e.g., traumatic brain injury, cerebral palsy, seizure disorder) or a severe behavioral disorder; 2) Medications to address seizures and/or disruptive or harmful behaviors have been optimized or not appropriate; 3) T [...]
- Safety enclosures used in hospitalized/agitated patients where enclosure is an alternative to standard restraints (supported by cited RCT and observational studies).
6 Active Policies
HUMANA-MEDICAL-SUPPLIES-EQUIPMENT-AND-APPLIANCES-DURABLE-MEDICAL-EQUIPMENT-VA-MEDICAID — Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - VIRGINIA
UHC-POL-beds-mattresses — Beds and Mattresses
ANTHEM-CG-DME-15 — CG-DME-15 Hospital Beds and Accessories
UMR-POL-UMR-beds-mattresses — Beds and Mattresses
Related Codes
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