Coverage Indications, Limitations, and/or Medical Necessity
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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 § (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:
For the items addressed in this LCD, the &#;reasonable and necessary&#; criteria, based on Social Security Act § (a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.
A fixed height hospital bed (E, E, E, E, and E) is covered if one or more of the following criteria (1-4) are met:
A variable height hospital bed (E, E, E, and E) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.
A semi-electric hospital bed (E, E, E, E, and E) is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.
A heavy duty extra wide hospital bed (E, E) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.
An extra heavy-duty hospital bed (E, E) is covered if the beneficiary meets one of the criteria for a hospital bed and the beneficiary's weight exceeds 600 pounds.
A total electric hospital bed (E, E, E, and E) is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.
For any of the above hospital beds (plus those coded E - see Policy Article Coding Guidelines), if documentation does not justify the medical need of the type of bed billed, payment will be denied as not reasonable and necessary.
If the beneficiary does not meet any of the coverage criteria for any type of hospital bed it will be denied as not reasonable and necessary.
ACCESSORIES:
Trapeze equipment (E, E) is covered if the beneficiary needs this device to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in or out of bed.
Heavy duty trapeze equipment (E, E) is covered if the beneficiary meets the criteria for regular trapeze equipment and the beneficiary's weight is more than 250 pounds.
A bed cradle (E) is covered when it is necessary to prevent contact with the bed coverings.
Side rails (E, E) or safety enclosures (E) are covered when they are required by the beneficiary's condition and they are an integral part of, or an accessory to, a covered hospital bed.
If a beneficiary's condition requires a replacement innerspring mattress (E) or foam rubber mattress (E) it will be covered for a beneficiary owned hospital bed.
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.
Medicare classifies hospital beds as durable medical equipment (DME), which is covered by Medicare Part B. Learn about eligiblity and out-of-pocket costs.
Medicare will pay for a hospital bed purchase or rental if it's considered medically necessary and prescribed by a doctor, and provided by a medical equipment provider approved by Medicare.
Medicare classifies hospital beds as durable medical equipment (DME), which is covered by Medicare Part B. However, there are some requirements you must meet for Medicare hospital bed coverage.
Additionally, even if Medicare does cover your hospital bed, there are some out-of-pocket costs you'll likely face. Learn more about your coverage.
Yes, Medicare will pay for hospital beds, if you meet certain conditions. Medicare does cover the cost of renting a hospital bed or purchasing one for home use if:
According to Medicare.gov, "Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. If your doctors or suppliers aren't enrolled, Medicare won't pay the claims submitted by them."1
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1-800-995-
If your hospital bed rental or purchase is approved for Medicare coverage, you pay 20 percent of the Medicare-approved amount of the hospital bed, and Medicare pays the other 80 percent.
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Before Medicare will pay its share, however, you must first meet your Part B deductible. In , the standard Medicare Part B deductible is $240 per year.
Medicare covers hospital bed rentals and purchases. After 13 months of renting your hospital bed, you will officially own it under current Medicare rules. The specific cost of your hospital bed may depend on factors such as:
Your doctor can tell you more about how much you'll likely pay for your hospital bed under Medicare.
Under Medicare's Competitive Bidding Program, DME suppliers submit bids to provide equipment to Medicare recipients living in or visiting competitive bidding areas. If you have Original Medicare and live in or are visiting a state in a competitive bidding area, you must get your DME from a contract supplier.
Refer to Medicare.gov to find out if you live in a competitive bidding area.
Or call now to speak with a licensed insurance agent:
1-800-995-
Medicare Part A covers inpatient hospital stays, as well as skilled nursing care, hospice care and limited home health services.
As an inpatient at a hospital, your Medicare Part A coverage includes the following:
Semi-private rooms
Meals
General nursing
Inpatient treatment drugs
Care as part of a qualifying clinical research study
Other hospital services and supplies
Not included are things like private-duty nursing, most private rooms, personal care items and television and services.
Before Medicare Part A will pay its share of a hospital stay, you must first meet your Medicare Part A deductible &#; $1,632 per benefit period (in ).
For lengthy hospitalizations, you may have to pay coinsurance based on the length of your stay (all costs listed are for ):
Days 1-60: $0 coinsurance
Days 61-90: $408 coinsurance per day
Days 91 and beyond: $816 coinsurance per each "lifetime reserve day." You have 60 lifetime reserve days.
Beyond lifetime reserve days: All costs.
Or call now to speak with a licensed insurance agent:
1-800-995-
Medicare Supplement Insurance plan (Medigap) helps pay for out-of-pocket costs associated with a hospital stay.
All Medigap plans offer coverage for the following hospital benefits:
Medicare Part A coinsurance and hospital costs
First three pints of blood if needed for a transfusion
Part A hospice care coinsurance or copayment
Some Medigap plans may also include coverage for:
Coinsurance for skilled nursing facility stay
Medicare Part A deductible
With 10 standardized Medigap plans to choose from in most states, you can find one that meets your needs. Call today to speak with a licensed insurance agent who can help you compare Medigap plans that are available where you live.
Important: Plan F and Plan C are not available to beneficiaries who became eligible for Medicare on or after January 1, .
Or call
1-800-995-to speak with a licensed insurance agent.
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