Group One – Preventive
- These are usually a mattress overlay or a foam mattress replacement. They may be covered if a patient is completely immobile, OR has limited mobility or any stage ulcer on the trunk or pelvic along with at least one of the following:
- Impaired nutritional status
- Altered sensory perception
- Compromised circulatory status
Group Two – Therapeutic
- Usually a powered pressure reducing mattress (such as air loss, alternating pressure) that can be placed directly on a hospital bed frame. It may be covered if the patient has:
- Multiple Stage II ulcers on trunk or pelvis, and
- Previous month of treatment on a Group I, and ulcers that has worsened or remained the same in the past month OR
- Large or multiple Stage II ulcers on trunk of pelvic, and
- Recent flap or graft surgery for an ulcer on the trunk or pelvis (60 days), and
- Previous use of a Group II or III surface immediately prior to a recent discharge from a facility (30 days).
Documentation – Written order and a CMN.