Does E0197 require prior authorization?

No, E0197 does not require prior authorization (high confidence). Code is covered without prior authorization.

Backwork Sign up free

`E0197`, Air pressure pad for mattress, standard mattress length and width

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without 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.
Suppliers must maintain proof of delivery (POD) documentation in their files and make POD available to the Medicare contractor upon request.

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.

7 Active Policies

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

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

Have a follow-up question?

Ask Backwork about documentation requirements, denial risks, or coverage in your state.

Ask Backwork about E0197 Sign up free

E0197, Air pressure pad for mattress, standard mattress length and width