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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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  1. The beneficiary is completely immobile - i.e., beneficiary cannot make changes in body position without assistance, or

  2. 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

  3. 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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  1. Impaired nutritional status

  2. Fecal or urinary incontinence

  3. Altered sensory perception

  4. 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. 

Pressure Reducing Support Surfaces: List
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