National Medical Policy

Transcription

1 National Medical Policy Subject: Policy Number Hospital Beds And Accessories NMP292 Effective Date*: September 2006 Updated: June 2017 This National Medical Policy is subject to the terms in the IMPORTANT NOTICE at the end of this document For Medicaid Plans: Please refer to the appropriate State's Medicaid manual(s), publication(s), citations(s) and documented guidance for coverage criteria and benefit guidelines prior to applying Health Net Medical Policies The Centers for Medicare & Medicaid Services (CMS) For Medicare Advantage members please refer to the following for coverage guidelines first: Use Source Reference/Website Link X National Coverage Determination (NCD) Durable Medical Equipment Reference List (280.1); Hospital Beds: X National Coverage Manual Citation Local Coverage Determination (LCD)* Hospital Beds and Accessories: X Article (Local)* Hospital Beds and Accessories- Policy Articleeffective Oct 2014: Other None Use Health Net Policy Instructions Hospital Beds and Accessories Jun 17 1

2 Medicare NCDs and National Coverage Manuals apply to ALL Medicare members in ALL regions. Medicare LCDs and Articles apply to members in specific regions. To access your specific region, select the link provided under Reference/Website and follow the search instructions. Enter the topic and your specific state to find the coverage determinations for your region. *Note: Health Net must follow local coverage determinations (LCDs) of Medicare Administration Contractors (MACs) located outside their service area when those MACs have exclusive coverage of an item or service. (CMS Manual Chapter 4 Section 90.2) If more than one source is checked, you need to access all sources as, on occasion, an LCD or article contains additional coverage information than contained in the NCD or National Coverage Manual. If there is no NCD, National Coverage Manual or region specific LCD/Article, follow the Health Net Hierarchy of Medical Resources for guidance. Current Policy Statement Health Net, Inc. considers use of a hospital bed in the home medically necessary durable medical equipment (DME) when any of the following are met: (also see Appendix I for bed types and indications) Fixed Height Hospital Bed Health Net, Inc. considers a fixed height hospital bed medically necessary DME in the home when any of the following is met: 1. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed (such as the head or foot of bed elevated to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections in patients with cardiac disease, chronic obstructive pulmonary disease, quadriplegia or paraplegia) 2. The patient requires the head of the bed to be elevated more than 30 degrees* most of the time due to left-sided congestive heart failure with orthopnea, or problems with aspiration. Pillows or wedges must have been tried and ruled out as sufficient, or 3. Special attachments that cannot be fixed and used on an ordinary bed (e.g., traction equipment) *Note: Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed because the use of pillows usually suffices. Variable Height Hospital Bed* Health Net, Inc. considers a manual or electric variable height hospital bed medically necessary DME if the patient meets one of the criteria for a fixed height hospital bed noted above and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position. This would be considered medically necessary if the patient had one of the following conditions: Severe arthritis and other injuries to lower extremities; (e.g. fractured hip). The condition requires the variable height feature to assist the patient to ambulate by enabling the patient to place his or her feet on the floor while sitting on the edge of the bed; Hospital Beds and Accessories Jun 17 2

3 Severe cardiac conditions. For those cardiac patients who are able to leave bed, but who must avoid the strain of jumping up or down; Severe spinal cord injuries, including quadriplegic and paraplegic patients, multiple limb amputee and stroke patients. For those patients who are able to transfer from bed to a wheelchair, with or without help; or Other severely debilitating diseases and conditions, if the variable height feature is required to assist the patient to ambulate. Semi-Electric Hospital Bed Health Net, Inc. considers a semi-electric hospital bed medically necessary DME if the patient meets one of the criteria for a fixed height bed and the patient is able to operate the controls and cause the adjustments and has a condition that requires frequent changes in body position and where there may be an immediate need for a change in body position (i.e., no delay can be tolerated), e.g., the Deluxe Franklin Bed. Heavy Duty Extra Wide Hospital Bed Health Net, Inc. considers a heavy duty extra wide hospital bed medically necessary DME if the patient meets one of the criteria for a fixed height hospital bed and the patient s weight is more than 350 pounds, but does not exceed 600 pounds. Extra Heavy Duty Hospital Bed Health Net, Inc. considers an extra heavy duty hospital bed medically necessary DME if the patient meets one of the criteria for a hospital bed and the patient s weight exceeds 600 pounds. Note: The term "bedfast" is defined as the patient being in bed at least 18 hours per day due to a severely debilitating medical condition that is expected to last at least one month. A "wheel-chair-bound" patient is one who is incapable of standing or walking on his/her own, and is therefore confined to a chair or wheelchair when out of bed. Accessories Health Net, Inc. considers any of the following accessories for hospital beds medically necessary DME when criteria have been met for a hospital bed and there is documentation to support the need for the accessory: Trapeze equipment if the patient is bed confined and needs a trapeze bar to sit up because of respiratory conditions, to change body position for other medical reasons, or to get in and out of bed. An attachable trapeze bar is not considered medically necessary when used on a nonhospital bed. Bed cradles for patients with acute gouty arthritis, diabetic ulcers, decubiti, or burns, when necessary to prevent contact with bed coverings. Reusable, autoclavable bedpans and urinals if the patient is bed confined. Side rails* for beds when the member's condition requires them (e.g., seizures, vertigo, disorientation, and neurological disorders). Hospital Beds and Accessories Jun 17 3

4 Innerspring/foam rubber mattresses as replacement mattresses only when the hospital bed is medically necessary. * Note: Side rails for beds are considered safety features; under most benefit plans, safety items are excluded from coverage. Under benefit plans with this exclusion. Not Medically Necessary Health Net, Inc. considers any of the following not medically necessary: Beds 1. Power or manual lounge beds as they are not primarily medical in nature, are not primarily used in the treatment of disease or injury, and are used for comfort or convenience. These beds, like ordinary beds, are typically sold as furniture. The following are examples of brands of lounge beds: Craftmatic Adjustable Bed Adjust-A-Sleep Adjustable Bed Electropedic Adjustable Bed Simmons Beautyrest Adjustable Bed Select Comfort Sleep Number Bed 3. A total electric hospital bed because the height adjustment feature is a convenience feature (e.g., The TotalCare Bariatric Bed). Health Net, Inc. considers the following types of beds as not medically necessary for use in the home setting: Ordinary beds typically sold as furniture because they are not primarily medical in nature, are not primarily used in the treatment of disease or injury, and are normally used in the absence of illness or injury Institutional-type hospital beds for home use, for example: kinetic therapy and continuous lateral rotation beds (Kinetic Therapy Triadyne Bed, Hill-Rom TotalCare SpO2RT) for the prevention or treatment of pressure sores or pulmonary complications because there is inadequate evidence in the peer-reviewed medical literature of their effectiveness Beds that provide vibration therapy or percussion therapy for preventing and treating pulmonary complications related to immobility are considered experimental and investigational because of a lack of adequate evidence in the peer-reviewed published medical literature of their effectiveness for this indication. Oscillating beds, Springbase beds, Circulating beds, Cage beds, Stryker frame beds Hospital Beds and Accessories Jun 17 4

5 Additional Information Appendix I Types of Hospital Beds DME Description (Codes) Height of Bed Bed Height Adjustment Head & Foot Adjustments Standard (E0250-E0251, E0290, E0291) Variable (E0255, E0256, E0292, E0293) Semi-electric (E0260, E0261, E0294, E0295) Total Electric (E0265, E0266, E0296, E0297) Heavy duty (E0301, E0303) Misc. DME (E0302, E0304) Fixed Not applicable Not applicable Variable Manual Manual Variable Manual Electric Variable Electric Electric Hospital bed capable of supporting patient weight of greater than 350 lbs. and less than or equal to 600 lbs. Hospital bed capable of supporting patient weight of greater than 600 lbs. Indications Type of Bed Standard hospital bed Variable height, semielectric and total electric bed Features Slightly higher than an ordinary bed Ability to adjust height of bed manually or electrically; it is rarely indicated for a patient to need a bed with an electric feature to adjust the height of the bed. In most cases a manual bed height adjuster will adequately meet all patients' needs. An electric bed height adjuster is not indicated for family and/or health care provider convenience in caring for the patient. Exceptions may be made in cases of spinal cord injury and head injury patients. Usual Indication Rarely indicated but may be used for situations that require special attachments for a bed, such as traction or side rails and the features of the adjustable bed height or adjustable head and foot features are not medically indicated. The ability to adjust the height of a bed is indicated for conditions that require or permit transfers to chair, wheelchair or standing position for patients that should not strain to get in or out of bed. Examples: 1. Severe arthritic and other injuries to lower extremities, e.g., fractured hip. The condition requires the variable height feature to assist patient to ambulate by enabling the patient to place his or her feet on the floor while sitting on the edge of the bed. 2. Severe cardiac conditions. For those cardiac patients who are able to leave bed, but who must avoid the strain of "jumping" up or down. 3. Spinal cord injuries, including quadriplegic and paraplegic patients, multiple limb amputee, and stroke patients. For those patients who are able to transfer from bed Hospital Beds and Accessories Jun 17 5

6 Variable semielectric or total electric bed Heavy duty hospital bed Ability to adjust the height of the head and foot feature manually or electrically: the decision as to whether a patient needs a bed with an electric feature to adjust either head and/or foot is indicated based on the need for immediate and or frequent changes in body position and the patient's ability to operate the controls and cause the adjustments. Exceptions may be made in cases of spinal cord injury and head injury patients. Ability to support the weight of obese bedfast patients to a wheelchair, with or without help. 4. Other severely debilitating diseases and conditions, if the variable height feature is required to assist the patient to ambulate. The ability to adjust the height of the head and/or foot of the bed is indicated for: assistance in transfers in and out of bed OR the patent's condition (e.g., cardiac disease, chronic obstructive pulmonary disease, quadriplegia or paraplegia) may require positioning of the body (such as elevation of the head at least 30 degrees or foot of bed to alleviate pain, promote good body alignment, prevent contractures, avoid respiratory infections) in ways not possible in an ordinary bed. Indicated for the use of bedfast obese patients. There are 2 types of heavy duty bed frames available depending on the weight of the patient. Codes Related To This Policy NOTE: The codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service described by this code is a covered or noncovered health service. Coverage is determined by the benefit documents and medical necessity criteria. This list of codes may not be all inclusive. On October 1, 2015, the ICD-9 code sets used to report medical diagnoses and inpatient procedures have been replaced by ICD-10 code sets. ICD-9 Codes (May not be all inclusive) Quadriplegia and quadriparesis Paraplegia Metastatic cancer to the bone (periosteum) ICD-10 Codes G82.20-G82.54 C76.0-C79.89 G73.1-G73.7 J44.0-J44.1 J96.10-J96.12 CPT Codes Paraplegia (paraparesis) and quadriplegia (quadriparesis) Secondary malignant neoplasm Disorders of myoneural junction and muscle in diseases classified elsewhere (exacerbations of neuromuscular disease) Chronic obstructive pulmonary disease Chronic respiratory failure Hospital Beds and Accessories Jun 17 6

7 N/A HCPCS Codes E0250 Hospital bed, fixed height, with any type side rails, with mattress E0251 Hospital bed, fixed height, with any type side rails, without mattress E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress E0260 Hospital bed, semi-electric, (head and foot adjustment), with any type side rails, with mattress E0261 Hospital bed, semi-electric, (head and foot adjustment), with any type side rails, without mattress E0265 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress E0266 Hospital bed, total electric, (head foot and height adjustments), with any type side rails, without mattress E0271 Mattress, innerspring E0272 Mattress, foam rubber E0280 Bed cradle, any type E0290 Hospital bed, fixed height, without side rails, with mattress E0291 Hospital bed, fixed height, without side rails, without mattress E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress E0301 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 lbs., but less than or equal to 600 lbs., with any type of side rails, without mattress E0302 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs., with any type side rails, without mattress E0303 Hospital bed, heavy duty, extra wide, with weight capacity greater than 350 lbs., but less than or equal to 600 lbs., with any type side rails, with mattress E0304 Hospital bed, extra heavy duty, extra wide, with weight capacity greater than 600 lbs., with any type side rails with mattress E0305 Bed side rails, half length E0310 Bed side rails, full length E0910 Trapeze bars, also known as Patient Helper, attached to bed, with grab bar E0911 Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, attached to bed, complete with grab bar E0912 Trapeze bar, heavy-duty, for patient weight capacity greater than 250 pounds, freestanding, complete with grab bar E0940 Trapeze bar, freestanding, complete with grab bar Scientific Rationale Hospital Beds and Accessories Jun 17 7

8 An ordinary bed is one that is generally sold as a furniture item and typically consists of a frame, box spring and mattress. It is of fixed height and does not allow adjustments to head or leg elevation, except for placement of pillows behind the upper torso or lower extremities. A hospital bed is one with manual head and leg elevation adjustments that provides the positioning required for a patient with certain medical condition(s). Some common diagnoses that may be considered medically necessary for a hospital bed include: (1) cancer with metastasis; (2) end stage respiratory failure; (3) end stage COPD; (4) quadriplegia/paraplegia; and (5) exacerbation of neuromuscular diseases. Review History September 2006 March 2007 August 2007 October 2010 July 2011 June 2012 June 2013 June 2014 June 2015 June 2016 June 2017 Medical Advisory Council initial approval Coding Updates Added Medicare criteria from the NCD on Hospital Beds to the section under Variable Height Feature. Codes reviewed. Update. Added Medicare Table with link to NCD. No revisions for Commercial members. Update. No revisions. Code Updates. Update. No Revisions. Update no revisions. Code updates Update no revisions Update no revisions Update no revisions Update no revisions. Code updates References - Update June Black J, Berke C, Urzendowski G. Pressure ulcer incidence and progression in critically ill subjects : influence of low air loss mattress versus a powered air pressure redistribution mattress. J Wound Ostomy Continence Nurs May;39 (3): Tzeng HM, Prakash F, Brehob M, et al. Keeping patient beds in a low position: An exploratory descriptive study to continuously monitor the height of patient beds in an adult acute surgical inpatient care setting. Contemp Nurse Apr 4. References Initial 1. Bein T, Metz C, Eberl P, Pfeifer M, Taeger K. Acute pulmonary and cardiovascular effects of continuous axial rotation (kinetic therapy) in respiratory failure. Schweiz Med Wochenschr Dec 3;124(48): Centers for Disease Control. Guideline for preventing nosocomial pneumonia: recommendations and reports Jan 3:46(RR);1-79. Accessed Nov 8, Available at: 3. Centers for Medicare & Medicaid Services (CMS). Medicare coverage database. National coverage determination for hospital beds (280.7). 4. CIGNA HealthCare Medicare Administration. Region D DMERC. Local medical review policy. Hospital beds and accessories. 5. Cullum N, McInnes E, Bell-Syer SEM, Legood R. Support surfaces for pressure ulcer prevention. The Cochrane database of Systematic Reviews. In: The Cochrane Library, Issue 4, Copyright 2005 The Cochrane Collaboration. 6. Nelson LD, Choi SC. Kinetic therapy in critically ill trauma patients. Clin Intensive Care. 1992;3(6): Hospital Beds and Accessories Jun 17 8

9 7. Staudinger T, Kofler J, Mullner M, et al. Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: results of a pilot study. Crit Care Med Jan;29(1): Traver GA, Tyler ML, Hudson LD, et al. Continuous oscillation: outcome in critically ill patients. J Crit Care Sep;10(3): Wang JY, Chuang PY, Lin CJ, Yu CJ, Yang PC. Continuous lateral rotational therapy in the medical intensive care unit. J Formos Med Assoc Nov;102(11): United HealthCare Medicare, DMERC Region A. Hospital beds, fixed height. Medical Policy. Minnetonka, MN: United Health Group; updated December 17, United HealthCare Medicare, DMERC Region A. Hospital beds, semi-electric. Medical Policy. Minnetonka, MN: United Health Group; updated December 20, United HealthCare Medicare, DMERC Region A. Hospital beds, total electric. Medical Policy. Minnetonka, MN: United Health Group; updated December 20, United HealthCare Medicare, DMERC Region A. Hospital beds, variable height. Medical Policy. Minnetonka, MN: United Health Group; updated December 20, United HealthCare Medicare, DMERC Region A. Trapeze bars and other bed accessories. Medical Policy. Minnetonka, MN: United Health Group; updated December 20, Australian Wound Management Association (AWMA), Pressure Ulcer Interest Sub-Committee. Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers. West Leederville, Australia: AWMA; Cullum N, Nelson EA, Flemming K, Sheldon T. Systematic reviews of wound care management: (5) beds; (6) compression; (7) laser therapy, therapeutic ultrasound, electrotherapy and electromagnetic therapy. Health Technol Assess. 2001;5(9): Martin AH. Should continuous lateral rotation therapy replace manual turning? Nurs Manage. 2001;32(8): Wang JY, Chuang PY, Lin CJ, et al. Continuous lateral rotational therapy in the medical intensive care unit. J Formos Med Assoc. 2003;102(11): Kirschenbaum L, Azzi E, Sfeir T, et al. Effect of continuous lateral rotational therapy on the prevalence of ventilator-associated pneumonia in patients requiring long-term ventilatory care. Crit Care Med. 2002;30(9): Davis K Jr, Johannigman JA, Campbell RS, et al. The acute effects of body position strategies and respiratory therapy in paralyzed patients with acute lung injury. Crit Care. 2001;5(2): Staudinger T, Kofler J, Mullner M, et al. Comparison of prone positioning and continuous rotation of patients with adult respiratory distress syndrome: Results of a pilot study. Crit Care Med. 2001;29(1): Meyers C, Low L, Kaufman L, et al. Trendelenburg positioning and continuous lateral rotation improve oxygenation in hepatopulmonary syndrome after liver transplantation. Liver Transpl Surg. 1998;4(6): Dolovich M, Rushbrook J, Churchill E, et al. Effect of continuous lateral rotational therapy on lung mucus transport in mechanically ventilated patients. J Crit Care. 1998;13(3): Basham KA, Vollman KM, Miller AC. To everything turn, turn, turn... An overview of continuous lateral rotational therapy. Respir Care Clin N Am. 1997;3(1): Hospital Beds and Accessories Jun 17 9

10 25. Whiteman K, Nachtmann L, Kramer D, et al. Effects of continuous lateral rotation therapy on pulmonary complications in liver transplant patients. Am J Crit Care. 1995;4(2): Patel UH, Jones JT, Babbs CF, et al. The evaluation of five specialized support surfaces by use of a pressure-sensitive mat. Decubitus. 1993;6(3):28-31, 34, Sahn SA. Continuous lateral rotational therapy and nosocomial pneumonia. Chest. 1991;99(5): Schimmel L, Civetta JM, Kirby RR. A new mechanical method to influence pulmonary perfusion in critically ill patients. Crit Care Med. 1977;5(6): Powers J, Daniels D. Turning points: Implementing kinetic therapy in the ICU. Nurs Manage. 2004;35(5):suppl Priestley MA, Helfaer MA. Approaches in the management of acute respiratory failure in children. Curr Opin Pediatr. 2004;16(3): Mullins CD, Philbeck TE Jr, Schroeder WJ, Thomas SK. Cost effectiveness of kinetic therapy in preventing nosocomial lower respiratory tract infections in patients suffering from trauma. Manag Care Interface. 2002;15(8): Fischer JA. How to promote pulmonary health with kinetic therapy. Nurs Manage. 2000;31(1): Raoof S, Chowdhrey N, Raoof S, et al. Effect of combined kinetic therapy and percussion therapy on the resolution of atelectasis in critically ill patients. Chest. 1999;115(6): Marik PE, Fink MP. One good turn deserves another! Crit Care Med. 2002;30(9): Bahzad MS, Jocelyn R, Chiddok DR, et al. The effect of continuous lateral rotation versus conventional critical care bed in the management of acute respiratory distress syndrome. Chest. 2002;122(4):53S-54S. 36. Stiletto R, Ose C, Folsch C. Positioning therapy in the treatment of severe oxygenation disorders in critically ill patients: Part I - Current status in the practical use of positioning therapy in German ICUs. Results of a randomized, cross-sectional trial. Int J Intensive Care. 2003; Pape HC. Is early kinetic positioning beneficial for pulmonary function in multiple trauma patients? Injury. 1998;29(3); Pape HC, Regel G, Borgmann W, et al. The effect of kinetic positioning on lung function and pulmonary hemodynamics in posttraumatic ARDS: A clinical study. Injury. 1994; 25(1) Dobson PS, Edbrooke DL, Reilly CS. The role of kinetic therapy in intensive care: The effects of immobilization and some possible solutions. Br J Intensive Care. 1993;3(10); Tillett JM, Marmarou A, Agnew JP, et al. Effect of continuous rotational therapy on intracranial pressure in the severely brain-injured patient. Clin Intensive Care. 1993;21(7): deboisblanc BP, Castro M, Everret B, et al. Effect of air-supported, continuous, postural oscillation on the risk of early ICU pneumonia in nontraumatic critical illness. Chest. 1993;103(5): Nelson LD, Choi SC. Kinetic therapy in critically ill trauma patients. Clin Intensive Care. 1992;3: Choi SC, Nelson LD. Kinetic therapy in critically ill patients. Combined results based on metaanalysis. J Crit Care. 1992;7(1): Hess D, Agarwal NN, Myers CL. Positioning, lung function and kinetic bed therapy. Resp Care. 1992;37(2): Sahn S. Continuous lateral rotational therapy and nosocomial pneumonia. Chest, 1991;99(5): Hospital Beds and Accessories Jun 17 10

11 46. Clemmer TP, Green S, Ziegler B, et al. Effectiveness of the kinetic treatment table for preventing and treating pulmonary complications in severely headinjured patients. Crit Care Med. 1990;18(6): Kelley RE, Bell LK, Mason RL. Cost Analysis of kinetic therapy in the prevention of complications of stroke. South Med J. 1990;18(6): Castro MS, Everett B, deboisblanc BP. Positioning patients with hypoxemia: Effect on physiology and outcome. Crit Care Rep. 1990;1(2): Fink MP, Helsmoortel CM, Stein KL, et al. The efficacy of an oscillation bed in the prevention of lower respiratory tract infection in critically ill victims if blunt trauma; A prospective study. Chest. 1990;97(1): Traver GA, Tyler ML, Hudson LD, et al. Continuous oscillation: Outcome in critically ill patients. J Crit Care. 1995;10(3): Murai DT, Grant JW. Continuous oscillation therapy improves the pulmonary outcome of intubated newborns: Results of a prospective, randomized, controlled trial. Crit Care Med. 1994;22(7): Shapiro MJ, Keegan MJ. Continuous oscillation therapy for the treatment of pulmonary contusion. Am Surg. 1992;58(9): Powell-Cope G, Baptiste AS, Nelson A. Modification of bed systems and use of accessories to reduce the risk of hospital-bed entrapment. Rehabil Nurs. 2005;30(1):9-17. Important Notice General Purpose. Health Net's National Medical Policies (the "Policies") are developed to assist Health Net in administering plan benefits and determining whether a particular procedure, drug, service or supply is medically necessary. The Policies are based upon a review of the available clinical information including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the drug or device, evidence-based guidelines of governmental bodies, and evidence-based guidelines and positions of select national health professional organizations. Coverage determinations are made on a case-by-case basis and are subject to all of the terms, conditions, limitations, and exclusions of the member's contract, including medical necessity requirements. Health Net may use the Policies to determine whether under the facts and circumstances of a particular case, the proposed procedure, drug, service or supply is medically necessary. The conclusion that a procedure, drug, service or supply is medically necessary does not constitute coverage. The member's contract defines which procedure, drug, service or supply is covered, excluded, limited, or subject to dollar caps. The policy provides for clearly written, reasonable and current criteria that have been approved by Health Net s National Medical Advisory Council (MAC). The clinical criteria and medical policies provide guidelines for determining the medical necessity criteria for specific procedures, equipment, and services. In order to be eligible, all services must be medically necessary and otherwise defined in the member's benefits contract as described this "Important Notice" disclaimer. In all cases, final benefit determinations are based on the applicable contract language. To the extent there are any conflicts between medical policy guidelines and applicable contract language, the contract language prevails. Medical policy is not intended to override the policy that defines the member s benefits, nor is it intended to dictate to providers how to practice medicine. Policy Effective Date and Defined Terms. The date of posting is not the effective date of the Policy. The Policy is effective as of the date determined by Health Net. All policies are subject to applicable legal and regulatory mandates and requirements for prior notification. If there is a discrepancy between the policy effective date and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. * In some states, prior notice or posting on the website is required before a policy is deemed effective. For information regarding the effective dates of Policies, contact your provider representative. The Policies do not include definitions. All terms are defined by Health Net. For information regarding the definitions of terms used in the Policies, contact your provider representative. Policy Amendment without Notice. Health Net reserves the right to amend the Policies without notice to providers or Members. In some states, prior notice or website posting is required before an amendment is deemed effective. No Medical Advice. Hospital Beds and Accessories Jun 17 11

12 The Policies do not constitute medical advice. Health Net does not provide or recommend treatment to members. Members should consult with their treating physician in connection with diagnosis and treatment decisions. No Authorization or Guarantee of Coverage. The Policies do not constitute authorization or guarantee of coverage of particular procedure, drug, service or supply. Members and providers should refer to the Member contract to determine if exclusions, limitations, and dollar caps apply to a particular procedure, drug, service or supply. Policy Limitation: Member s Contract Controls Coverage Determinations. Statutory Notice to Members: The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract. The determination of coverage for a particular procedure, drug, service or supply is not based upon the Policies, but rather is subject to the facts of the individual clinical case, terms and conditions of the member s contract, and requirements of applicable laws and regulations. The contract language contains specific terms and conditions, including pre-existing conditions, limitations, exclusions, benefit maximums, eligibility, and other relevant terms and conditions of coverage. In the event the Member s contract (also known as the benefit contract, coverage document, or evidence of coverage) conflicts with the Policies, the Member s contract shall govern. The Policies do not replace or amend the Member s contract. Policy Limitation: Legal and Regulatory Mandates and Requirements The determinations of coverage for a particular procedure, drug, service or supply is subject to applicable legal and regulatory mandates and requirements. If there is a discrepancy between the Policies and legal mandates and regulatory requirements, the requirements of law and regulation shall govern. Reconstructive Surgery CA Health and Safety Code requires health care service plans to cover reconstructive surgery. Reconstructive surgery means surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) To improve function or (2) To create a normal appearance, to the extent possible. Reconstructive surgery does not mean cosmetic surgery," which is surgery performed to alter or reshape normal structures of the body in order to improve appearance. Requests for reconstructive surgery may be denied, if the proposed procedure offers only a minimal improvement in the appearance of the enrollee, in accordance with the standard of care as practiced by physicians specializing in reconstructive surgery. Reconstructive Surgery after Mastectomy California Health and Safety Code requires treatment for breast cancer to cover prosthetic devices or reconstructive surgery to restore and achieve symmetry for the patient incident to a mastectomy. Coverage for prosthetic devices and reconstructive surgery shall be subject to the co-payment, or deductible and coinsurance conditions, that are applicable to the mastectomy and all other terms and conditions applicable to other benefits. "Mastectomy" means the removal of all or part of the breast for medically necessary reasons, as determined by a licensed physician and surgeon. Policy Limitations: Medicare and Medicaid Policies specifically developed to assist Health Net in administering Medicare or Medicaid plan benefits and determining coverage for a particular procedure, drug, service or supply for Medicare or Medicaid members shall not be construed to apply to any other Health Net plans and members. The Policies shall not be interpreted to limit the benefits afforded Medicare and Medicaid members by law and regulation. Hospital Beds and Accessories Jun 17 12