PRESSURE REDUCING SUPPORT SURFACES
A Group 1 mattress overlay or mattress is covered if one of the following three criteria are met:
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The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or
The beneficiary has limited mobility - i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.
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Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):
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Impaired nutritional status
Fecal or urinary incontinence
Altered sensory perception
Compromised circulatory status
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** When the coverage criteria for a Group 1 mattress overlay or mattress are not met, the claim will be denied as not reasonable and necessary.