This policy version was replaced June 27, 2022. To find the newest version, go to https://www.bluecrossmn.com/providers/medical-policy-and-utilization-management, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Pressure-reducing support surfaces are used to prevent or promote the healing of specific types of pressure ulcers by reducing or eliminating tissue interface pressure.

Group 1 Pressure Reducing Support Surfaces

A Group 1 mattress overlay or mattress may be considered MEDICALLY NECESSARY AND APPROPRIATE when ONE of the following criteria are met:

• Member is completely immobile (i.e., cannot make changes in body position without assistance); OR
• Member cannot independently make changes in body position significant enough to alleviate pressure and has at least one of the following conditions:
  1. Impaired nutritional status;
  2. Fecal or urinary incontinence;
  3. Altered sensory perception;
  4. Compromised circulatory status.
• OR
• Member has any stage pressure ulcer on the trunk or pelvis and at least one of the following conditions:
  1. Impaired nutritional status;
  2. Fecal or urinary incontinence;
  3. Altered sensory perception;
  4. Compromised circulatory status.

Group 2 Pressure Reducing Support Surfaces

Initial use of a Group 2 pressure reducing support surface (i.e., alternating pressure and low air loss mattress and overlay) may be considered MEDICALLY NECESSARY AND APPROPRIATE when AT LEAST ONE of the following criteria are met:

• Multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month and member has been on a comprehensive ulcer treatment program for at least one month including each of the following:
  1. Use of an appropriate Group 1 support surface; and
  2. Regular assessment by a nurse, physician or other licensed healthcare practitioner; and
  3. Appropriate turning and positioning; and
  4. Appropriate wound care; and
  5. Appropriate management of moisture/incontinence; and
  6. Nutritional assessment and intervention consistent with overall plan of care.
• OR
• Large or multiple stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer(s) on the trunk or pelvis and member cannot be positioned off the ulcer areas; OR
• Myocutaneous flap or skin graft surgery for a pressure ulcer on the trunk or pelvis within the past 60 days; and member has been on a Group 2 or 3 pressure reducing support surface immediately prior to discharge from a hospital or other inpatient setting (discharge within the past 30 days).

Continued use of a Group 2 support surface after the initial approval for healing of stage II, III, or IV pressure ulcers may be considered MEDICALLY NECESSARY AND APPROPRIATE until the ulcer has healed or, if healing does not continue, there is documentation in the medical record that:

• Other aspects of the care plan are being modified to promote healing; AND
• The member continues to meet medical necessity criteria for a Group 2 support surface listed above.

Continued use of a Group 2 pressure reducing support surface following a myocutaneous flap or skin graft, maybe considered MEDICALLY NECESSARY AND APPROPRIATE for up to 60 days from the date of surgery.

Group 3 Pressure Reducing Support Surfaces

Initial use of a Group 3 pressure reducing support surface (i.e., air-fluidized bed) may be considered MEDICALLY NECESSARY AND APPROPRIATE when ALL of the following criteria are met:

• Stage III (i.e., full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer; AND
• Bedridden or chair-bound as a result of severely limited mobility; AND
• In the absence of an air-fluidized bed, the member would require care in a hospital or other inpatient setting; AND
• A documented order for the air-fluidized bed from the member's physician based upon a comprehensive assessment and evaluation of the member after completion of a course of conservative treatment designed to optimize conditions that promote wound healing. The evaluation generally must be performed within one month prior to initiation of therapy with the air-fluidized bed; AND
• The course of conservative therapy must have been at least one month in duration without progression toward wound healing. This month of prerequisite conservative treatment may include some period in a hospital or other active inpatient setting as long as there is documentation available to verify that the necessary conservative treatment was rendered. Conservative treatment must include:
  1. Frequent repositioning of member with particular attention to relief of pressure over bony prominences (usually every two hours); and
  2. Use of a Group 2 support surface to reduce pressure and sheer forces on healing ulcers and to prevent new ulcer formation; and
  3. Necessary treatment to resolve any wound infection; and
  4. Optimization of nutrition status to promote wound healing; and
  5. Debridement by any means, including wet-to-dry gauze dressings to remove devitalized tissue from the wound bed; and
  6. Maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings protected by an occlusive covering, while the wound heals.
• AND
• A trained adult caregiver is available to assist the member with activities of daily living (ADLs), 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; AND
• A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; AND
• All other alternative equipment has been considered and ruled out.

Continued use of a Group 3 surface (i.e., air-fluidized bed) may be considered MEDICALLY NECESSARY AND APPROPRIATE when the treating physician re-certifies the following on a monthly basis:

• Stage III or IV pressure ulcer; AND
• Member is bedridden or chair-bound as a result of severely limited mobility; AND
• All other alternative equipment has been considered and ruled out; AND
• Other aspects of the care plan are being modified to promote healing.

After six months on a Group 3 support surface with no improvement in the member's condition, alternative treatments must be considered before additional monthly authorization.

An air-fluidized bed is considered NOT MEDICALLY NECESSARY AND APPROPRIATE under any of the following circumstances:

• The member has co-existing pulmonary disease (the lack of back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions);
• The member requires treatment with wet soaks or moist wound dressing not protected with an impervious covering unless the member is undergoing aggressive treatment in a wound clinic and is showing measurable improvement.