These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.
Prior authorization is required except for members enrolled in a hospice program.
Generally covered subject to the indications listed below and per your member contract.
Indications that are covered
All of the following must be met to qualify for coverage:
- The member has a Stage 3 (full thickness tissue loss) or Stage 4 (deep tissue destruction) pressure sore.
- The member is bedridden or chair bound as a result of severely limited mobility.
- In the absence of an air-fluidized bed, the member would require institutionalization.
- The air-fluidized bed is ordered based upon a comprehensive assessment and evaluation of the member after conservative treatment has been tried without success. The member must generally have been on the conservative treatment program for at least one month prior to use of the air-fluidized bed with worsening or no improvement of the ulcer. The evaluation generally must be performed within a week prior to initiation of therapy with the air-fluidized bed. Treatment should generally include:
- Education of the member and caregiver on the prevention and/or management of pressure ulcers.
- Assessment by a physician, nurse, or other licensed health care practitioner at least weekly.
- Appropriate turning and positioning.
- Use of a Group 2 support surface, if appropriate.
- Appropriate wound care.
- Appropriate management of moisture/incontinence.
- Nutritional assessment and intervention consistent with the overall plan of care.
- A trained adult caregiver is available to assist the member with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems, such as leakage.
- A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis.
- All other alternative equipment has been considered and ruled out.
The continued medical necessity of an air fluidized bed must be documented by the treating physician every month. Continued use of an air fluidized bed is covered until the ulcer is healed or, if healing does not continue, there is documentation to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the bed is medically necessary for wound management.
Indications that are not covered
- The member has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions).
- The member requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering, such as plastic wrap or other occlusive material.
- The caregiver is unwilling or unable to provide the type of care required by a member on an air-fluidized bed.
- Structural support is inadequate to support the weight of the air-fluidized bed system.
- Electrical system is insufficient for the anticipated increase in energy consumption.
- Other known contraindications exist.
An air-fluidized bed uses warm air, under pressure, to set silicone coated ceramic beads in motion. This simulates the movement of fluid. When the member is in this bed, the body weight is evenly distributed over a large surface area. This creates a sensation of floating, aids in the healing of skin pressure sores and helps to prevent further skin breakdown. These beds are a group III pressure reducing support surface and are identified by Medicare HCPC code E0194.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.
Items must be received from a contracted vendor for in-network benefits to apply.
This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.