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||Craniectomy or craniotomy and other cranial surgeries|
|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|