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Aetna Aetna
Clinical Policy Bulletin:
Safety Items
Number: 0623


Policy

Notes:

Most standard Aetna benefit plans specifically exclude coverage of safety items.  Examples of safety items include adaptive full-length side safety rail (SleepSafe) beds, manual or electric safety bed systems (e.g., KayserBetten Secure Sleep Systems), bed exit monitors, bed rails, belts, car seats, fall detection systems, fire extinguishers, first aid kits, harnesses, helmets*, knee and elbow pads, restraints, safety goggles, smoke and carbon monoxide detectors, telephone alert systems, as well as automatic external defibrillators for home use (except for wearable automatic external defibrillators for members who meet the medical necessity criteria set forth in Aetna CPB 0585 - Cardioverter-Defibrillators).

Aetna standard HMO-based plans typically exclude "coverage furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury."  Standard Aetna non-HMO plans typically exclude charges "for care furnished mainly to provide a surrounding free from exposure that can worsen the person's disease or injury."  Under these plans, safety interventions and devices are excluded from coverage regardless of whether they are an integral and medically necessary component of the management of the member's condition.

Automatic external defibrillators (e.g., the HeartSine Samaritan PAD, HeartSine Technologies, Inc., San Clemente, CA; and the HeartStart Home OTC Defibrillator, Philips Medical Systems, Seattle, WA) are considered non-covered safety items under these plans, except for wearable automatic external defibrillators that are used as an alternative to implantable cardioverter defibrillators for members who meet the medical necessity criteria set forth in CPB 0585 - Cardioverter-Defibrillators.  In addition, use of automatic external defibrillators by lay persons is considered experimental and investigational because they have not been proven to reduce mortality compared to implantable cardioverter defibrillators or cardiopulmonary resuscitation by first responders.  For a review of the evidence, see CPB 0585 - Cardioverter-Defibrillators.

For non-standard plans that do not exclude coverage of safety items, Aetna covers safety items for members with diseases or medical conditions that: (i) place them at increased risk of injury; and/or (ii) make them especially susceptible to harm from injury.  However, many safety devices may be excluded from coverage because they do not meet Aetna's definition of covered durable medical equipment (DME).  Safety items that are normally of use in the absence of illness or injury do not meet Aetna's definition of covered DME. Under plans that do not exclude safety items, continuously worn prefabricated or custom-made soft or hard specialized medical protective helmets are considered medically necessary to prevent injury due to frequent, violent or uncontrolled seizures, balance disorders, head banging behaviors, or following cranial surgery. Annual replacement of the replacement liner is considered medically necessary and covered for persons who qualify for coverage of a specialized helmet.

Telephone alert systems are not considered by Aetna to fall within the contractual definition of DME in that they are normally of use in the absence of illness or injury. (Telephone alert systems relay pre-programmed messages to pre-determined telephone contacts when an individual activates a distress signal.  The distress signal activator is worn as a necklace or bracelet). In addition, telephone alert systems are considered safety items, which are contractually excluded under most benefit plans. Please check benefit plan descriptions for details.

* A specialized helmet may be covered as a prosthetic of the skull when medically necessary after cranial surgery. For cranial remodeling helmets/bands for plagiocephaly, see CPB 379 - Cranial Remodeling.



Background

An assessment on automated external defibrillators for home use published by Canadian Coordinating Office for Health Technology Assessment (Murray and Steffensen, 2005) concluded that no prospective studies showed that the use of automated external defibrillators in the home by untrained individuals improves health outcomes.  The assessment stated that more research is needed to ascertain the benefit and harm of the home use of automated external defibrillators. An assessment by the Ontario Ministry of Health and Long-term Care (MAS, 2005; Sharieff, et al., 2007) reached similar conclusions, stating that further research is needed to examine the benefit of in-home use of automated external defibrillators in patients at high risk of cardiac arrest.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
Other CPT codes related to the CPB:
61304 - 61619
HCPCS codes not covered for indications listed in the CPB::
A8000 Helmet, protective, soft, prefabricated, includes all components and accessories [covered as a prosthetic of the skull when medically necessary after cranial surgery]
A8001 Helmet, protective, hard, prefabricated, includes all components and accessories [covered as a prosthetic of the skull when medically necessary after cranial surgery]
A8002 Helmet, protective, soft, custom fabricated, includes all components and accessories [covered as a prosthetic of the skull when medically necessary after cranial surgery]
A8003 Helmet, protective, hard, custom fabricated, includes all components and accessories[covered as a prosthetic of the skull when medically necessary after cranial surgery]
A8004 Soft interace for helmet, replacement only
E0241 Bathtub wall rail, each
E0242 Bathtub rail, floor base
E0243 Toilet rail, each
E0300 Pediatric crib, hospital grade, fully enclosed, with or without top enclosure
E0305 Bedside rails, half-length
E0310 Bedside rails, full-length
E0316 Safety enclosure frame / canopy for use with hospital bed, any type
E0617 External defibrillator with integrated electrocardiogram analysis
E0700 Safety equipment (e.g., belt, harness or vest)
E0710 Restraint, any type (body, chest, wrist or ankle)
S0504 Single vision prescription lens (safety, athletic, or sunglass), per lens
S0506 Bifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0508 Trifocal vision prescription lens (safety, athletic, or sunglass), per lens
S0510 Non-prescription lens (safety, athletic, or sunglass), per lens
S0516 Safety eyeglass frames
S5160 Emergency response system; installation and testing
S5161 Emergency response system; service fee, per month (excludes installation and testing)
S5162 Emergency response system; purchase only
T1005 Positioning seat for persons with special orthopedic needs
T1014 Telehealth transmission, per minute, professional services bill separately


The above policy is based on the following references:
  1. U.S. Department of Health and Human Services, Public Health Service, Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd ed. Washington, DC: U.S. Government Printing Office; 1998.
  2. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services: Report of the U.S. Preventive Services Task Force. 2nd ed. Baltimore, MD: Williams & Wilkins; 1996.
  3. American Academy of Pediatrics. Selecting and using the most appropriate car safety seats for growing children: Guidelines for counseling parents. Pediatrics. 2002;109(3):550-553.
  4. Everitt V, Bridel-Nixon J. The use of bed rails: Principles of patient assessment. Nurs Stand. 1997;12(6):44-47.
  5. Werner P, Koroknay V, Cohen-Mansfield J. To use physical restraints or not. J Am Geriatr Soc. 1997;45(2):253.
  6. Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 1999;(4):CD001855.
  7. Werner P. Perceptions regarding the use of physical restraints with elderly persons: Comparison of Israeli health care nurses and social workers. J Interprof Care. 2002;16(1):59-68.
  8. Murray CL, Steffensen I. Automated external defibrillators for home use. Issues In Emerging Health Technologies. Issue 69. Ottawa, ON: Canadian Coordinating Office for Health Technology Assessment (CCOHTA); June 2005. Available at: https://www.ccohta.ca/publications/pdf/363_external_defrib_cetap_e.pdf. Accessed September 1, 2005.
  9. Ontario Ministry of Health and Long-term Care, Medical Advisory Secretariat (MAS). Use of automated external defibrillators in cardiac arrest. An evidence-based analysis. Toronto, ON: MAS; December 2005;5(19).
  10. Sharieff W, Kaulback K. Assessing automated external defibrillators in preventing deaths from sudden cardiac arrest: An economic evaluation. Int J Technol Assess Health Care. 2007;23(3):362-367.
  11. SleepSafe Beds, LLC. The SleepSafe [website]. Callaway, VA; SleepSafe Beds; 2008. Available at: http://www.sleepsafebed.com/. Accessed August 5, 2008.
  12. Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012;(1):CD008931.  


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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