Support Overlay

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These items require a written order prior to delivery. Refer to the Policy Article for additional information on orders.

 A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:

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

  2. The patient has limited mobility - i.e., patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or

  3. The patient has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below.

 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):

A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status