Does E0185 require prior authorization?

Yes, E0185 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

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`E0185`, Gel or gel-like pressure pad for mattress, standard mattress length and width

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before claim submission for items covered by this policy.
For DMEPOS base items requiring Written Order Prior to Delivery (WOPD), the supplier must receive a signed SWO/WOPD before delivering the item to the beneficiary.
For base items requiring WOPD, the WOPD must list the base item and may list separately billed associated options/accessories/supplies prior to delivery; the signed WOPD must be on file before billing associated items.

Patients using pressure-reducing support surfaces should have a care plan, which has been established by the patient's physician and home care nurse, which is documented in the patient's medical records, and which generally should include the following: Appropriate management of moisture/incontinence; Appropriate turning and positioning; Appropriate wound care (for stage II, III, or IV ulcer); Education of the patient and caregiver on the prevention and/or management of pressure ulcers; Nutritional assessment and intervention consistent with the overall plan; Regular assessment by a nurse, physician, or other licensed healthcare practitioner.

Key Coverage Criteria

A Group 1 mattress overlay or mattress (HCPCS: E0181, E0182, E0184, E0185, E0186, E0187, E0188, E0189, E0196, E0197, E0198, E0199, A4640) is covered when the beneficiary is completely immobile (cannot make changes in body position without assistance).
A Group 1 mattress overlay or mattress (same HCPCS list) is covered when the beneficiary has limited mobility (cannot independently change position enough to alleviate pressure) AND at least one of: impaired nutritional status; fecal or urinary incontinence; altered sensory perception; or compromised circulatory status.
A Group 1 mattress overlay or mattress (same HCPCS list) is covered when the beneficiary has any stage pressure ulcer on the trunk or pelvis AND at least one of: impaired nutritional status; fecal or urinary incontinence; altered sensory perception; or compromised circulatory status.
The provided support surface must not 'bottom out' when tested by palpation at the beneficiary's coccyx or lateral trochanter in supine (head flat), supine (head elevated ≤30°), and side-lying positions.
A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets: Altered sensory perception
A group 2 support surface is considered medically necessary DME when: The member has multiple stage II (partial thickness skin loss) pressure ulcers located on the trunk or pelvis, AND The member has been on a comprehensive ulcer treatment program for at least the past month, which has included the use of an appropriate group 1 support surface, AND The member's ulcers have worsened or remained the same over the past month.

8 Active Policies

ANTHEM-CG-DME-16, Pressure Reducing Support Surfaces - Groups 1, 2 & 3

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33830, Pressure Reducing Support Surfaces - Group 1

AETNA-CPB-0430, Pressure Reducing Support Surfaces

BCBSIL-DME101.001, Hospital Beds and Related Equipment

BCBSMT-DME101.001, Hospital Beds and Related Equipment

BCBSNM-DME101.001, Hospital Beds and Related Equipment

BCBSOK-DME101.001, Hospital Beds and Related Equipment

`E0185`, Gel or gel-like pressure pad for mattress, standard mattress length and width

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

E0185, Gel or gel-like pressure pad for mattress, standard mattress length and width

Prior Authorization

Documentation Required

Key Coverage Criteria

8 Active Policies

Related Codes

Have a follow-up question?

`E0185`, Gel or gel-like pressure pad for mattress, standard mattress length and width