Pressure Reducing Support Surfaces

Number: 0430

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses pressure reducing support surfaces.

1. Medical Necessity

   Aetna considers pressure-relieving support surfaces medically necessary as durable medical equipment (DME) according to the selection criteria set forth below. See Appendix for definitions and instructions relevant to interpretation of this policy.

   1. Group 1 Support Surfaces

      A group 1 mattress overlay or mattress is considered medically necessary DME when the member meets:

      1. Criterion a (below); or
      2. Criteria b or c and at least one of criteria d to g (below):
         
         
         1. Completely immobile – i.e., member can not make changes in body position without assistance.
         2. Limited mobility – i.e., member can not independently make changes in body position significant enough to alleviate pressure
         3. Any stage pressure ulcer on trunk or pelvis
         4. Impaired nutritional status
         5. Fecal or urinary incontinence
         6. Altered sensory perception
         7. Compromised circulatory status.

      A group 1 support surface is considered experimental, investigational, or unproven when these criteria are not met because of insufficient evidence in the peer-reviewed literature.

   2. Group 2 Pressure Reducing Support Surfaces

      Alternating Pressure, Low Air Loss Mattresses, Overlays and Underlays

      A group 2 support surface is considered medically necessary DME when the member meets:

      1. Criteria a and b and c (below); or
      2. Criterion d; or
      3. Criteria e and f (below):
         
         
         1. The member has multiple stage II (partial thickness skin loss) pressure ulcers located on the trunk or pelvis.
         2. The member has been on a comprehensive ulcer treatment programFootnote* for at least the past month, which has included the use of an appropriate group 1 support surface.
         3. The member's ulcers have worsened or remained the same over the past month.
         4. The member has large or multiple stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer(s) on the trunk or pelvis.
         5. The member has had a recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days).
         6. The member has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

      Footnote1* The comprehensive ulcer treatment described in this criterion should generally include:

      1. Appropriate management of moisture/incontinence;
      2. Appropriate turning and positioning;
      3. Appropriate wound care (for stage II, III, or IV ulcer);
      4. Education of the member and caregiver on the prevention and/or management of pressure ulcers;
      5. Nutritional assessment and intervention consistent with the overall plan of care;
      6. Regular assessment by the nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a member with a stage III or stage IV ulcer).

      If the member is on a group 2 surface, there should be a care plan established by the physician or home care nurse, which includes the above elements.

      When a group 2 support surface is prescribed for a myocutaneous flap or skin graft, continued use is generally considered medically necessary for up to 60 days from the date of surgery.

      Use of a group 2 support surface is considered medically necessary until the ulcer is healed or, if healing does not continue, there is documentation in the medical record to show:

      1. Other aspects of the care plan are being modified to promote healing, or
      2. The use of the alternating pressure mattress is medically necessary for wound management. 

      A group 2 support surface is considered experimental, investigational, or unproven when these criteria are not met because of insufficient evidence in the peer-reviewed literature.

   3. Group 3 Pressure Reducing Support Surfaces

      Air-Fluidized Beds (Bead Beds)

      An air-fluidized bed is considered medically necessary DME only when all of the following criteria are met:

      1. The member has a stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure ulcer

         1. A stage III or stage IV pressure ulcer of the foot does not require an air-fluidized bed because the foot can be elevated to relieve pressure;
         2. If the member is on an air-fluidized bed and an ulcer is less than 8 square centimeters and/or it is in an area other than the posterior trunk or pelvis, the attending physician must document why an alternative support surface would not be medically effective; and
      2. The member is bedridden or chair bound as a result of severely limited mobility; and
      3. In the absence of an air-fluidized bed, the member would require institutionalization (i.e., hospitalization or placement in a nursing home); and
      4. The air-fluidized bed is ordered in writing by the member's attending physician based upon a comprehensive assessment and evaluation of the member after conservative treatmentFootnote** has been tried without success. The evaluation generally must be performed within a week prior to initiation of therapy with the air-fluidized bed; and
      5. A trained adult caregiver is available to assist the member with activities of daily living, fluid balance, dry skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed treatments, and management and support of the air-fluidized bed system and its problems such as leakage; and
      6. A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized bed on a monthly basis; and
      7. All other alternative equipment have been considered and ruled out.

      Footnote2**The conservative treatment program should generally include:

      1. Appropriate management of moisture/incontinence;
      2. Appropriate turning and positioning;
      3. Appropriate wound care;
      4. Assessment by a physician, nurse, or other licensed healthcare practitioner at least weekly;
      5. Education of the member and caregiver on the prevention and/or management of pressure ulcers;
      6. Nutritional assessment and intervention consistent with the overall plan of care;
      7. Use of a group 2 support surface, if appropriate.

      The member must generally have been on the conservative treatment program for at least 1 month prior to use of the air-fluidized bed with worsening or no improvement of the ulcer. 

      Continued use of an air-fluidized bed is considered medically necessary until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that:

      1. Other aspects of the care plan are being modified to promote healing; or
      2. The use of the bed is medically necessary for wound management.

      Examples of brands of group 3 support surfaces (air-fluidized beds) include the Clinitron, the Envella Bed, Fluid Air, and Mediscus Heavy Duty System.

   4. Sheepskin and Lambswool Pads

      Medical necessity criteria for sheepskin and lambswool pads are the same as for alternating pressure pads and mattresses (group 2 pressure-reducing support surfaces).

   5. Decubitus Care Accessories

      1. Bed blanket cradle (keeps bed covers from touching affected skin) are considered medically necessary for diabetic ulcers, decubiti or burns, or gouty arthritis.
      2. Heel or elbow protectors are considered medically necessary.

   6. Bottoming Out

      For all types of support surfaces, the support surface provided for the member should be one in which the member does not “bottom out”. Bottoming out is the finding that an outstretched hand can readily palpate the bony prominence (coccyx or lateral trochanter) when it is placed palm up between the undersurface of the overlay or mattress and in an area under the bony prominence. This bottoming out criterion should be tested with the member in the supine position with their head flat, in the supine position with their head slightly elevated (no more than 30 degrees), and in the sidelying position. Support surfaces that do not prevent bottoming out are considered not medically necessary.

2. Experimental, Investigational, or Unproven

   Aetna considers the following experimental, investigational, or unproven:

   1. An air-fluidized bed when the aforementioned criteria are not met because of insufficient evidence in the peer-reviewed literature;
   2. An air-fluidized bed has no proven value for persons with any of the following contraindications:
      
      
      1. Electrical system is insufficient for the anticipated increase in energy consumption;
      2. Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 1,600 pounds or more);
      3. The caregiver is unwilling or unable to provide the type of care required by the member on an air-fluidized bed;
      4. The member has co-existing pulmonary disease (the lack of firm back support makes coughing ineffective and dry air inhalation thickens pulmonary secretions);
      5. The member requires treatment with wet soaks or moist wound dressings that are not protected with an impervious covering such as plastic wrap or other occlusive material; or
      6. Other known contraindications to use of an air-fluidized bed exist;

   3. Fluid Immersion Simulation (FIS) system (e.g., Dolphin FIS is considered institutional equipment that is inappropriate for home use. There is no high‑quality direct evidence supporting the effectiveness of FIS systems in the home setting for either treatment or prevention of pressure ulcers. The clinical evidence is limited to institutional use.

3. Policy Limitations and Exclusions 

   1. Air-fluidized bed

      Coverage of an air-fluidized bed is limited to the equipment itself. Architectural adjustments such as electrical or structural improvements for the air-fluidized bed are generally excluded from coverage. In addition, services of informal caregivers are excluded from coverage. Please check benefit plan descriptions.

   2. Ordinary, consumer-grade air mattresses

      Aetna does not cover ordinary, consumer-grade air mattresses that do not meet Aetna's contractual definition of durable medical equipment (DME) (i.e., because they are not durable (made to withstand prolonged use), not mainly used in the treatment of disease or injury, and are normally of use to persons who do not have a disease or injury). Please check benefit plan descriptions for details. The following are examples of proprietary products that are not covered (not an all-inclusive list):
      
      

      1. Air Flow Mat air-filled vibrating mattress
      2. Air-O-Pad air mattress

   Consistent with DME MAC policy:

   Treating practitioner means physician (MD or DO) or physician assistant, nurse practitioner, or clinical nurse specialist. A prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.

   A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.

   There must be sufficient medical information included in the medical record to demonstrate that all applicable coverage criteria are met.

   Consistent with DME MAC policy:

   Supplier prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician.

   "Neither a practitioner’s order, nor a supplier-prepared statement, nor a practitioner’s attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating practitioner or supplier. There must be information in the member’s medical record that supports the medical necessity for the item and substantiates the information on a supplier-prepared statement or treating practitioner’s attestation (if applicable)."

   "Forms are subject to corroboration with information in the medical record."

   Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary. 

   Consistent with DME MAC policy:

   A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted.  If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not medically necessary.

   The SWO must contain all the following elements:

   • Member's name or identification number
   • Order date
   • General description of the item
     
     
     • The description can be either a HCPCS code, a HCPCS code narrative, or a brand name/model number
     • In addition to the description of the base item, the SWO must include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
     • For supplies -- In addition to the description of the base item, the order/prescription must include all concurrently ordered supplies that are separately billed (List each separately)
       
       
   • Each item or service requested must individually list the HCPCS code (Procedure code) and quantity to be dispensed
   • Treating practitioner name and national provider identifier (NPI)
   • Treating practitioner's signature.

4. Related Policies

   1. CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters)
   2. CPB 0429 - Bathroom and Toilet Equipment and Supplies
   3. CPB 0434 - Therapeutic Chairs
   4. CPB 0456 - Pillows and Cushions
   5. CPB 0459 - Seat Lifts and Patient Lifts
   6. CPB 0505 - Ambulatory Assist Devices: Walkers, Canes, and Crutches
   7. CPB 0543 - Hospital Beds and Accessories
   8. CPB 0623 - Safety Items

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
Pressure reducing support surfaces:
HCPCS codes covered if selection criteria are met:
A4640	Replacement pad for use with medically necessary alternating pressure pad owned by patient
E0181	Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
E0182	Pump for alternating pressure pad, for replacement only
E0183	Powered pressure reducing underlay/pad, alternating, with pump, includes heavy duty
E0184	Dry pressure mattress
E0185	Gel or gel-like pressure pad for mattress, standard mattress length and width
E0186	Air pressure mattress
E0187	Water pressure mattress
E0188	Synthetic sheepskin pad
E0189	Lambswool sheepskin pad, any size
E0191	Heel or elbow protector, each
E0193	Powered air flotation bed (low air loss therapy)
E0196	Gel pressure mattress (nonpowered)
E0197	Air pressure pad for mattress, standard mattress length and width
E0198	Water pressure pad for mattress, standard mattress length and width
E0199	Dry pressure pad for mattress, standard mattress length and width
E0277	Powered pressure-reducing air mattress
E0280	Bed cradle, any type
E0370	Air pressure elevator for heel
E0371	Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372	Powered air overlay for mattress, standard mattress length and width
E0373	Nonpowered advanced pressure reducing mattress
HCPCS codes not covered for indications listed in the CPB:
Dolphin Fluid Immersion Simulation (FIS) – no specific code
ICD-10 codes covered if selection criteria are met (not all-inclusive):
L89.101 - L89.159	Pressure ulcer of back
L89.200 - L89.229	Pressure ulcer of hip
L89.301 - L89.329	Pressure ulcer of buttock
L89.40 - L89.45	Pressure ulcer of contiguous site of back, buttock and hip
L89.810 - L89.899	Pressure ulcer of other site
R40.0	Somnolence
R40.1	Stupor
R40.3	Persistent vegetative state
R40.4	Transient alteration of awareness
Z74.01	Bed confinement status
Air-fluidized beds:
HCPCS codes covered if selection criteria are met:
E0194	Air fluidized bed
ICD-10 codes covered if selection criteria are met (not all-inclusive):
I96	Gangrene, not elsewhere classified
L89.101 - L89.159	Pressure ulcer of back
L89.200 - L89.229	Pressure ulcer of hip
L89.301 - L89.329	Pressure ulcer of buttock
L89.40 - L89.45	Pressure ulcer of contiguous site of back, buttock and hip
R64	Cachexia
Z74.01	Bed confinement status
ICD-10 codes not covered for indications listed in the CPB:
J40 - J47.9	Chronic lower respiratory diseases
J86.0 - J94.9 J96.00 - J99	Other diseases of respiratory system
L89.500 - L89.629	Pressure ulcer of ankle or heel
M86.071 - M86.079 M86.171 - M86.179 M86.271 - M86.279 M86.371 - M86.379 M86.471 - M86.479 M86.571 - M86.579 M86.671 - M86.679 M86.8x7, M86.9 M89.671 - M89.679 M90.871 - M90.879	Osteomyelitis, periostitis, and other infections involving bone, ankle and foot

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Background

Pressure‑reducing (pressure‑redistributing) support surfaces are specialized mattresses, mattress overlays, and bed systems designed to reduce tissue interface pressure, shear, and microclimate stress—key extrinsic factors in the development and progression of pressure ulcers/injuries.

Pressure ulcers, commonly referred to as bedsores, are localized areas of skin and soft‑tissue damage caused by prolonged pressure, shear, or friction, most often occurring over bony prominences such as the sacrum, hips, and heels. The primary causes include immobility, friction, and inadequate blood flow and are traditionally described across four stages, ranging from non‑blanchable erythema of intact skin to deep wounds with exposed muscle or bone. These type of injuries are managed through pressure redistribution, wound care, nutritional optimization, and surgical intervention when indicated.

In 2016, the National Pressure Injury Advisory Panel updated the preferred clinical terminology to “pressure injury” to more accurately reflect that tissue damage may exist with either intact skin or open wounds and to encompass early and deep tissue injuries that are not ulcers in the classic sense. Despite this terminology update, the Centers for Medicare & Medicaid Services (CMS) continues to use the term “pressure ulcer” in National and Local Coverage Determinations because Medicare rely on standardized, auditable diagnosis code titles to ensure uniform payment, regulatory compliance, and consistent quality measurement over time. Although CMS permits the use of “pressure injury” terminology in clinical documentation, these conditions remain coded, reported, and evaluated for medical necessity under the established pressure ulcer framework, requiring alignment of modern clinical language with legacy reimbursement structures (CMS, 2024; Edsberg et al., 2016; Zaidi and Sharma, 2024).

Pressure-relieving support surfaces are designed to prevent or promote the healing of pressure ulcers by reducing or eliminating tissue interface pressure. Most of these devices reduce interface pressure by conforming to the contours of the body so that pressure is distributed over a larger surface area rather than concentrated on a more circumscribed location.

The purpose of this clinical policy bulletin (CPB) is to provide guidance on the selection of support surfaces. This assessment provides a comparative evaluation of alternating air mattresses (such as the Pegasus Airwave System), air-fluidized beds (such as the Clinitron bed), and low-air-loss mattresses (such as the Flexicair bed). This CPB addresses coverage of mattress overlays and underlays, specialized mattresses, and specialty beds. Such devices are made entirely of foam, are constructed of an outer membrane that encases a gel, foam, air, water, or polyfill, or are engineered to fluidize ceramic beads.

This clinical policy on pressure-relieving support surfaces is based on Medicare criteria and on the recommendations of the AHCPR Treatment of Pressure Ulcers Guidelines Panel. Use of low-air-loss beds and air-fluidized beds is reserved for patients with stage III and stage IV ulcers. Because pressure-reducing support surfaces can be developed and marketed without efficacy studies, few data exist to recommend their rational use. In the absence of evidence demonstrating differences in efficacy between air-fluidized beds, low-air-loss beds, and alternating air mattresses, it is reasonable to reserve treatment with the most expensive of these three types of support surfaces for patients with ulcers that have failed to heal with one of the other types of beds.

The AHCPR Guidelines on Treatment of Pressure Ulcers (1994) provides an algorithm for the selection of overlays and mattresses. Low-air-loss beds and air-fluidized beds are reserved for patients with multiple, large, truncal stage III or IV ulcers and for patients who have bottomed out on a dynamic overlay or mattress. It is reasonable to first try a low-air-loss bed (such as a Flexair) or a dynamic overlay (such as a Pegasus Airwave) and progress to an air-fluidized bed (such as a Clinitron) if it appears that the patient's ulcer is not healing properly.

No conclusions about the comparative efficacy of the low-air-loss bed, the alternating air mattress, and the air-fluidized bed can be drawn from available evidence because of a lack of studies that compare these support surfaces to each other. Published studies of support surfaces have compared air-flotation beds or alternating air mattresses to static support surfaces or regular mattresses. The Treatment of Pressure Ulcers Guidelines Panel found that “[n]o studies have compared the effectiveness of low-air-loss beds and air-fluidized beds.” The Panel concluded that “[a] randomized controlled trial will be required to compare low-air-loss bed and air-fluidized bed therapy.”

An issue of Clinics in Geriatric Medicine (Remsberg and Bennett, 1997) was devoted to the treatment of pressure ulcers. Experts on pressure ulcers, including several members of the AHCPR's Treatment of Pressure Ulcers Guidelines Panel, reviewed the medical literature that has appeared since the publication of the AHCPR pressure ulcer guidelines. Remsberg and Bennett (1997) reviewed the literature on overlays, replacement mattresses, and specialty beds. The authors concluded: "Expensive low-air-loss beds and air-fluidized beds have been inadequately studied, and their use is usually driven by reimbursement issues and the experience and biases of nurses and physicians. Although two randomized prospective trials showed that healing rates were statistically superior for these expensive devices, one study did not demonstrate superior healing. In all of these studies, some patients developed new sores despite treatment on the specialty surfaces. In addition to statistical superiority, clinical significance must also be evaluated. For example, in the only randomized trial assessing the efficacy of air-fluidized beds, even the authors noted that the reported outcome differences (0.5 cm² median increase in surface area in the control group versus 1.2 cm² median decrease in the treatment group) were hardly clinically impressive. In a large retrospective descriptive study, the observation was made that many patients who were admitted to a long-stay hospital for treatment of severe pressure sores on air-fluidized beds died within the first 30 days after admission. Since no discernible pressure sore healing occurred for these patients before they died, the issue of futility must be considered when making treatment decisions for similar patients."

In a Cochrane review, McInnes et al. (2011) evaluated the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. These investigators searched the Cochrane Wounds Group Specialised Register (searched July 15, 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3); Ovid MEDLINE (2007 to Week 1 of July 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 14, 2011); Ovid EMBASE (2007 to Week 27 of 2011); EBSCO CINAHL (2007 to July 14, 2011). The reference sections of included studies were also searched. They included published or unpublished randomized controlled trials (RCTs) that assessed the effects of support surfaces for treating pressure ulcers, in any patient group or setting that reported an objective measure of wound healing. Data extraction and assessment of risk of bias were performed independently by two review authors. Trials with similar patients, comparisons, and outcomes were considered for pooled analysis. Where pooling was inappropriate, the results of the trials were reported narratively. Where possible, the risk ratio or mean difference was calculated for the results of individual studies. These researchers identified 18 trials of support surfaces for pressure ulcer treatment, involving 1,309 participants with sample sizes that ranged from 14 to 160. Of three trials comparing air-fluidized devices with conventional therapy, two reported significant reductions in pressure ulcer size associated with air-fluidized devices. Due to a lack of reported variance data, these investigators could not replicate the analyses. In relation to three of the trials that reported significant reductions in pressure ulcer size favoring low-air-loss devices compared with foam alternatives, they found no significant differences. A small trial found that sheepskin placed under the legs significantly reduced redness, and similarly, a small subgroup analysis favored a profiling bed compared with a standard bed in terms of the healing of existing grade 1 pressure ulcers. Poor reporting, clinical heterogeneity, lack of variance data, and methodological limitations in the eligible trials meant that no pooled comparisons were undertaken. The authors concluded that there is no conclusive evidence about the superiority of any support surface for the treatment of existing pressure ulcers. Methodological issues included variations in outcomes measured, sample sizes, and comparison groups. Many studies had small sample sizes, and often there was inadequate description of the intervention, standard care, and co-interventions. Individual study results were often inadequately reported, with failure to report variance data common, thus hindering the calculation of mean differences. Some studies did not report P values when reporting on differences in outcomes. In addition, the age of some trials (some being 20 years old) meant that other technologies may have superseded those investigated. They stated that further and rigorous studies are required to address these concerns and to improve the evidence base before firm conclusions can be drawn about the most effective support surfaces to treat pressure ulcers.

Colin et al. (2012) stated that the use of support surfaces in the prevention and treatment of pressure ulcers is an important part of care for a patient at risk and/or suffering from sore(s). These researchers examined which support surfaces to use in the prevention and treatment of at-risk and/or pressure sore patients. They performed a systematic review of the literature querying several databases, including Pascal Biomed, PubMed, and the Cochrane Library, from 2000 through 2010. In prevention, a structured foam mattress is more efficient than a standard hospital mattress. An alternating pressure mattress is more effective than a visco-elastic mattress in limiting the occurrence of heel pressure ulcers, but those that do occur are more serious. A low-air-loss bed is more efficient than a mixed pulsating air mattress in the prevention of heel pressure ulcers. Some types of sheepskin can reduce sacral pressure ulcer incidence in orthopedic patients. The use of an overlay on an operating table limits the occurrence of peri-operative and post-operative pressure ulcers. An air-fluidized bed improves pressure ulcer healing. The authors concluded that the data in the literature are not always relevant and do not suffice to dictate a clinician's choices. These investigators noted that they were compelled to recognize the methodological limitations of many studies, the lack of corporate interest in conducting such studies, and the relatively small number of available trials. However, the effectiveness of some support surfaces reaches a sufficient level of evidence, especially when they are associated with postural, hydration, and nutritional measures. They stated that support surfaces are recommended in the prevention and treatment of patients at risk and/or already suffering from pressure ulcers, and their use should constitute part of an overall preventive or curative strategy.

Tricco et al. (2015) stated that numerous, often multi-faceted regimens are available for treating complex wounds, yet the evidence of these interventions is recondite across the literature. These researchers identified effective interventions to treat complex wounds through an overview of systematic reviews. MEDLINE (OVID interface, 1946 until October 26, 2012), EMBASE (OVID interface, 1947 until October 26, 2012), and the Cochrane Database of Systematic Reviews (Issue 10 of 12, 2012) were searched on October 26, 2012. Systematic reviews that examined adults receiving care for their complex wounds were included. Two reviewers independently screened the literature, abstracted data, and assessed study quality using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Overall, 99 systematic reviews were included after screening 6,200 titles and abstracts and 422 full texts; 54 were systematic reviews with a meta-analysis (including data on over 54,000 patients), and 45 were systematic reviews without a meta-analysis. Overall, 44% of included reviews were rated as being of high quality (AMSTAR score greater than or equal to 8). Based on data from systematic reviews including a meta-analysis with an AMSTAR score greater than or equal to 8, promising interventions for complex wounds were identified. These included bandages or stockings (multi-layer, high compression) and wound cleansing for venous leg ulcers; four-layer bandages for mixed arterial/venous leg ulcers; biologics, ultrasound, and hydrogel dressings for diabetic leg/foot ulcers; hydrocolloid dressings, electrotherapy, air-fluidized beds, and alternate foam mattresses for pressure ulcers; and silver dressings and ultrasound for unspecified mixed complex wounds. For surgical wound infections, topical negative pressure and vacuum-assisted closure were promising interventions, but this was based on evidence from moderate to low-quality systematic reviews. The authors concluded that numerous interventions can be utilized for patients with varying types of complex wounds, yet few treatments were consistently effective across all outcomes throughout the literature. Clinicians and patients can use these results to tailor effective treatment according to the type of complex wound. Network meta-analysis will be of benefit to decision-makers, as it will permit multiple treatment comparisons and ranking of the effectiveness of all interventions.

Griffey and colleagues (2021) stated that healing of severe pressure injuries (PIs) in patients with multiple comorbidities requires a multi-faceted and interdisciplinary approach and includes the use of support surfaces. Published clinical data guiding support surface selection are very limited. Long-term acute care hospitals frequently treat medically complex patients, many with severe PIs. In a case-series study, these researchers compared healing rates in patients with severe PIs on air-fluidized therapy (AFT) or fluid immersion system (FIS) support surfaces. After obtaining informed consent, patients with a stage 3 or 4 PI were randomized to receive either AFT or FIS in addition to the standard of care (SOC). Baseline and weekly wound measurements were obtained using a three-dimensional (3D) camera measurement tool. The required sample size was calculated to be 60. After the study had started, the long-term acute care hospital admission criteria changed, severely limiting the number of patients who met the study inclusion criteria. Only four patients with a stage 4 PI completed the study. Of those, two were on an AFT and two were on an FIS surface. All wounds reduced in size; 0.12 and 0.57 cm²/day for patients on AFT and 0.68 and 1.34 cm²/day for patients on FIS. All but one wound had a reduction in wound volume ranging from -0.2 and 0.97 cm³ to 1.78 and 4.18 cm³/day for patients on AFT and FIS, respectively. The authors concluded that obtaining much-needed evidence to guide support surface selections for patients with severe PIs is challenging and requires multi-center studies. These researchers noted that this trial did not achieve enrollment goals; they presented the data that were available and recognized the limited generalizability of these data. These investigators stated that more research using larger sample sizes is needed to determine the therapeutic benefit of these measures to enable evidence-based decision-making.

Soppi et al. (2021) stated that the pathophysiological cascade of pressure ulcer (PU) development consists of tissue deformation, inflammation, and hypoxia. In a cross-over study, deformation was measured with computed tomography (CT) linked with contact area reflecting immersion and envelopment. Inflammation and hypoxia were measured using sub-epidermal moisture (SEM), skin temperature, and tissue perfusion with positron emission tomography (PET). These variables were examined under 90 minutes of pressure exposure caused by two functionally different support surfaces—a regular foam mattress and a minimum pressure air (MPA) mattress. A total of eight healthy volunteers participated in the study. There was major tissue deformation when the participants lay on a foam mattress, while the tissues retained their original shape on the MPA mattress (p < 0.0001). During the pressure exposure, the skin temperature increased significantly on both support surfaces; however, the final temperature on the foam mattress was about 1 degree C higher than on the MPA mattress (p < 0.0001). SEM increased on both support surfaces compared with an unexposed reference site; however, the cause may be different between the two support surfaces. Tissue perfusion was lowest in the skin, followed by subcutaneous tissues, and highest in the muscles. The pressure exposure did not cause any substantial changes in perfusion. The results showed that tissue deformation was more pronounced, the support surface contact area (envelopment) was smaller, and the skin temperature was higher on the foam mattress than on the MPA mattress, without significant differences in tissue perfusion. The authors concluded that in this study, the MPA mattress support surface had mechano-biological properties that counteracted tissue deformation and thereby may prevent PUs. This was a small (n = 8) study, and the participants were healthy volunteers.

Air-Filled Immersion and Envelopment Support Surface (Non-fluidized, No Beads)

An air‑filled immersion and envelopment support surface is a powered mattress replacement system composed of multiple adjustable air‑filled chambers or bladders that allow the patient’s body to sink (immerse) and conform (envelop) into the surface. Pressure redistribution is achieved through increased body‑surface contact area and reduced peak interface pressures, without the use of fluidized particulate media. These systems rely on immersion and envelopment achieved through air alone, without the use of fluidized beads, and may be powered to dynamically adjust internal air distribution in response to patient weight, position, and movement. Air‑filled immersion surfaces are designed to reduce pressure, tissue deformation, and shear forces and may be used for patients at high risk of pressure injury or with existing pressure injuries who require greater pressure redistribution than provided by standard surfaces. These mattresses may incorporate low‑air‑loss for microclimate management. Low‑air‑loss (LAL) refers to the controlled escape of air through the support surface to assist with heat and moisture dissipation at the skin–support interface. LAL is a feature, not a standalone classification, and does not independently define the level of pressure redistribution provided. An example includes the Agiliti Immerse low air loss immersion therapy mattress, which is considered a powered, pressure-reducing air mattress (low-air-loss) designed to prevent and treat pressure ulcers/injuries.

Air-Fluidized Therapy Support Surface (Fluidized Microspheres with Airflow)

Air‑fluidized therapy support surfaces are powered bed systems containing microsphere beads through which heated, pressurized air is continuously circulated to create a fluid‑like medium. The patient is supported on a fluidized surface, resulting in minimal shear forces and very low interface pressures.

These systems are designed to deliver maximal pressure redistribution for patients with severe or refractory pressure injuries. Pressure redistribution is achieved by forcing air through millions of fine silicone beads, producing a fluid‑like state that allows deep immersion and envelopment, thereby distributing body weight over a broad surface area and minimizing tissue deformation over bony prominences.

Clinical evidence and national guidelines support the use of air‑fluidized therapy in appropriately selected patients as part of a comprehensive pressure injury prevention and treatment program.

Smith et al. (2013) highlighted that pressure ulcers impact up to 3 million Americans, contributing significantly to morbidity, mortality, and healthcare costs. The study aimed to summarize the effectiveness and safety of various treatment strategies for adults with pressure ulcers. Researchers conducted a comprehensive review of literature from multiple databases, including MEDLINE, EMBASE, and the Cochrane Database, covering studies from January 1985 to October 2012. They selected randomized trials, comparative observational studies, and noncomparative intervention series involving more than 50 participants for surgical interventions and harm evaluations. A total of 174 studies met the inclusion criteria, with 92 focusing on complete wound healing. The findings indicated that moderate-strength evidence supports the use of air-fluidized beds, protein-containing nutritional supplements, radiant heat dressings, and electrical stimulation in enhancing pressure ulcer healing compared to standard care, placebo, or sham interventions. Additionally, low-strength evidence suggested benefits from alternating-pressure surfaces, hydrocolloid dressings, platelet-derived growth factor, and light therapy. However, the applicability of these results is limited due to variations in study quality, methods, outcomes, and insufficient duration for assessing complete wound healing. Overall, the study concluded that moderate-strength evidence demonstrates improved healing of pressure ulcers in adults with the aforementioned treatment modalities.

VanWyhe and Willer (2018) noted that in their hospital, air-fluidized therapy beds were used for all patients undergoing surgery for the creation of myocutaneous flaps. These beds were associated with staff injuries, and patients reported dissatisfaction. The WOC nurses were asked to find an alternative support surface for post-myocutaneous flap patients. These investigators reported findings from five patients placed on a low air loss immersion mattress following myocutaneous flap surgery. On week 2, per the authors’ hospital clinical pathway, all were transferred to their critical access hospitals with the immersion therapy mattress. Upon discharge, all flap incisions were approximated and closed. The authors concluded that their experiences with these five cases suggested that a support surface combining immersion and low air loss features was a viable alternative to an air-fluidized bed for the post-operative management of patients undergoing myocutaneous flap surgery for the management of full-thickness pressure injuries. These researchers stated that as a result of their experiences in these five cases, they continued to use the support surface described in this article for the post-operative management of patients undergoing myocutaneous flap surgery for the management of full-thickness pressure injuries (PIs). They were also examining its role in the prevention and management of stage III and stage IV PIs. This was a small (n = 5) study; its findings need to be validated by well-designed studies.

McIntosh et al. (2025) conducted a study to investigate the impact of using an air-fluidized therapy (AFT) bed versus a low-air-loss (LAL) surface bed on wound healing and progression in patients with deep tissue pressure injuries (DTPIs). This retrospective, comparative descriptive study reviewed the electronic medical records of 18 patients diagnosed with DTPIs located in the sacral, coccygeal, and ischial areas, consisting of 10 men and 8 women with a mean age of 62.6 years (SD 15.9), at an academic level 1 trauma health center in the Southeastern United States. Medical records were identified through the Hospital-Acquired Pressure Injury (HAPI) Debrief Tool, a secure clinical database managed by nursing wound care specialists. The study measured the size of the initial, worst, and final DTPIs in square centimeters and compared changes in surface area between the AFT and LAL groups using Wilcoxon rank-sum tests. Results showed that 10 patients were placed on the AFT bed while 8 were on the LAL surface bed, with similar median initial wound sizes: 11.9 cm² (IQR 6.0, 19.5) for the AFT group and 4.7 cm² (IQR 3.3, 22.5) for the LAL group (P = .2636). The AFT group exhibited no change in wound size from initial to worst (0.0 cm², IQR 0.0, 0.0) compared to a significant increase of 6.8 cm² (IQR 1.8, 61.5) in the LAL group (P = .0050). Furthermore, the change from initial to final wound size was -7.4 cm² (IQR -16.5, -3.7) for the AFT group, indicating healing, while the LAL group showed an increase of 5.1 cm² (IQR 1.8, 25.8) (P = .0178). These findings suggest that using an AFT bed may reduce wound progression and enhance healing compared to an LAL bed for patients with DTPIs.

Fluid Immersion Simulation System

A fluid immersion simulation (FIS) system is a type of advanced therapeutic support surface designed to redistribute pressure and reduce mechanical stress on skin and underlying tissues in patients at high risk for pressure injury or those recovering from surgical wound closure. FIS systems use a sealed mattress filled with fluid‑like material that allows the patient to sink into the surface, simulating immersion while maintaining support and minimizing peak interface pressures, shear, and friction. Unlike air‑fluidized beds, traditional FIS systems do not inherently provide active microclimate management (temperature and moisture control) and may require adjunctive technologies to address heat and moisture accumulation. These systems are intended for use in acute and post‑acute care settings as part of comprehensive pressure ulcer prevention and post‑operative management strategies, particularly following reconstructive flap procedures.

The Dolphin Fluid Immersion Simulation (FIS) mattress (Joerns Healthcare) is a powered therapeutic support surface designed to redistribute pressure and reduce tissue deformation by simulating immersion in a fluid medium, thereby minimizing interface pressure, shear, and friction. The system uses automated, patient‑specific adjustments based on weight and body contour to create a near‑neutral buoyant state and has been clinically evaluated primarily in hospital and facility‑based settings, including postoperative management following surgical flap closure of stage III and IV pressure ulcers and in patients at high risk for pressure injury. While the Dolphin FIS is FDA‑cleared as a medical device and may be provided as durable medical equipment for use in the home, such in‑home use reflects the site of service rather than a separate clinical indication, and typically requires caregiver support and clinical oversight. Importantly, the published clinical evidence supporting the Dolphin FIS— including a prospective randomized controlled trial—was generated largely in inpatient postoperative populations, and the device does not inherently provide active microclimate (temperature and moisture) management, which may be clinically relevant when extrapolating outcomes to other care settings.

According to the Wound Systems website, the Dolphin Bed surface replaces the standard hospital bed mattress and is also available in bariatric sizes. The pump/controller fits on the foot of the bed and includes an onboard rechargeable battery for power interruption protection and mobility. Battery operation capability also permits the controller to be adapted to a wheelchair, providing a continuum of pressure reduction wound care and patient mobility. The application of the Fluid Immersion Simulation (FIS) technology provides dynamic pressure reduction adjustments every 11 seconds to keep the patient at equilibrium. The Dolphin System is often purported as a clinically effective, cost-reduced alternative to Air Fluidized Therapy (AFT).

Mendoza et al. (2019) conducted a prospective, single‑center, randomized controlled midpoint analysis comparing a fluid immersion simulation (FIS) support surface with a standard air‑fluidized bed (AFB) for acute postoperative management following surgical closure of stage III–IV pressure ulcers. Twenty‑five subjects (12 FIS, 13 AFB) were analyzed after operative closure and 14 days of assigned therapy, with the primary endpoint being wound closure status at postoperative day 14 and secondary endpoints including postoperative wound complications and patient and nurse acceptability. Rates of wound closure at 2 weeks were similar between groups (FIS 85% vs AFB 83%, P = .99), indicating no difference in short‑term closure success. However, the FIS group experienced a higher frequency of wound complications—particularly dehiscence and maceration—although most were minor and self‑resolving, with clinically significant events occurring in a small subset. Patient and nurse acceptability scores modestly favored the FIS system but were not statistically significant. Despite higher complication rates and longer hospital stays in the FIS group, the authors concluded that FIS was non‑inferior to AFB in short‑term postoperative closure outcomes, though the small sample size, substantial loss to follow‑up, and imbalance in clinical severity limit generalizability, underscoring the need for larger trials with longer follow‑up to assess recurrence and long‑term outcomes.

ClimateCare (Joerns Healthcare) is a powered mattress coverlet system designed to provide active microclimate management by controlling temperature and moisture at the interface between the patient and the support surface. It is intended for use in conjunction with pressure redistribution mattresses, such as Fluid Immersion Simulation (FIS) systems, to address key contributors to tissue breakdown. By promoting effective moisture vapor transfer and thermal regulation, ClimateCare is part of a system that uses air flow to manage heat and moisture at the skin surface to reduce the risk of pressure ulcers. The system operates independently of the mattress, uses a single‑patient‑use coverlet, and is designed for easy installation. ClimateCare is FDA‑cleared under a 510(k) exemption for medical use (Joshi et al., 2022).

Joshi et al. (2022) conducted a prospective, single‑center randomized controlled trial of 80 adults undergoing flap closure of stage III–IV pressure ulcers, comparing a Fluid Immersion Simulation (FIS) system with an Air‑Fluidized Bed (AFB), which the authors describe as standard of care. The primary endpoint—successful wound closure at postoperative day 14—was similar between groups (open wounds: FIS 14.3% vs. AFB 12.5%; p=0.84). Likewise, no statistically significant differences in wound status were observed at 1 month, 6 months, or 1 year of follow‑up. However, early postoperative complications within 14 days were significantly higher in the FIS group (40.6% vs. 17.5%; p=0.0296), primarily due to moisture‑related issues such as maceration and minor dehiscence. After mid‑study introduction of ClimateCare, a microclimate‑management cover, complication rates and early wound failures in the FIS group decreased and approached those seen with AFB; however, this finding is limited by its post‑hoc, non‑randomized nature. Overall, the study suggests similar short‑ and long‑term closure outcomes between FIS and AFB, but a higher risk of early complications with FIS alone, with outcomes potentially improved by adjunctive microclimate management.

Garg et al. (2025) conducted a single‑center randomized controlled trial evaluating ClimateCare, a microclimate‑management mattress coverlet, in patients undergoing surgical closure of stage III or IV pressure ulcers. All participants were managed on a Fluid Immersion Simulation (FIS) system, with 18 patients receiving adjunctive ClimateCare and 14 serving as controls, and outcomes were assessed over 14 days postoperatively. The study demonstrated a significantly lower rate of postoperative complications in the ClimateCare group (17% vs. 71%; p=0.001) and no open wounds at postoperative day 14, compared with 33% of controls (p=0.01), while patient‑reported comfort, mobility, and pain were similar between groups. The authors concluded that ClimateCare used in conjunction with FIS may reduce early postoperative complications by addressing moisture and microclimate factors. However, the findings are limited by the small sample size, single‑center design, convenience sampling leading to potential selection bias, patient heterogeneity, and variability in wound characteristics, as well as a relatively short primary follow‑up, despite some longer‑term complication capture. Larger, multi‑center studies with more diverse populations and extended follow‑up are needed to confirm generalizability and durability of outcomes.

Shi et al. (2021) synthesized evidence from 13 randomized controlled trials evaluating multiple support surfaces (beds, overlays, and mattresses) for the treatment of existing pressure ulcers across care settings and found that the overall certainty of evidence was predominantly low to very low. Across four main comparisons—alternating pressure (active) air versus foam surfaces, reactive air versus foam surfaces, reactive water versus foam surfaces, and Nimbus versus Pegasus alternating pressure air systems—there was substantial uncertainty regarding differences in complete pressure ulcer healing, patient comfort, and adverse events, largely due to small sample sizes, short and variable follow‑up, and high or unclear risk of bias. Reactive air surfaces showed low‑certainty evidence suggesting a potential increase in the likelihood of ulcer healing over approximately 37.5 days when time‑to‑healing was considered, but not consistently when assessed as a proportion healed, and this potential benefit was offset by higher costs per ulcer‑free day. No clear advantages were demonstrated for reactive water surfaces or between different alternating pressure systems. All included participants were adults (predominantly older, with a median age >80 years), studies were geographically limited to Europe and North America, and methodological limitations—including imprecision, incomplete outcome data, and unblinded outcome assessment—further constrained confidence in the findings. Overall, the review concludes that current evidence is insufficient to definitively determine the superiority of any specific support surface for pressure ulcer healing, with only cautious, short‑term signals favoring reactive air surfaces over foam in some settings.

A 2022 scoping review specifically examining pressure injury prevention and management in home care settings found that "the use of protocols for the prevention and management of pressure injuries, including evidence-based interventions in home care, and adherence to existing protocols were low". The review identified a significant gap in research regarding pressure injury preventive measures in home environments and called for "comprehensive observational and randomized controlled studies" in home care settings (Karadağ  et al., 2022).

There is no high‑quality direct evidence supporting the effectiveness of FIS systems in the home setting for either treatment or prevention of pressure ulcers. The limited clinical evidence for FIS comes almost entirely from acute, inpatient postoperative populations, most notably the single‑center randomized study by Mendoza et al. (2019), which evaluated short‑term postoperative use (14 days) following surgical closure of stage III–IV pressure ulcers. That study did not include home use, did not assess independently mobile or caregiver‑managed patients, and involved intensive inpatient nursing oversight. No randomized controlled trials, prospective cohort studies, or guideline recommendations were identified that evaluate FIS use in private homes, home health, or long‑term community discharge settings. Furthermore, complications observed with FIS (e.g., maceration and dehiscence), likely related to limited microclimate management, raise additional concerns in the home environment where moisture control, repositioning adherence, and clinical monitoring are less reliable. As such, current evidence is insufficient to establish medical necessity for FIS systems in the home.

Fluidized Positioner for the Prevention of Occipital Pressure Injury

In a quality improvement project, Byfield (2022) examined if head immobilization, pressure re-distribution for the occiput, and off-loading of pressure from craniotomy incisions could be improved by means of fluidized positioners instead of pillows previously used as the SOC. A total of 8 patients with head trauma and craniotomy in a surgical intensive care unit (SICU) and cardiovascular intensive care unit (CVICU) from a level 1 trauma center in the Southeast region of the U.S. participated over a 6-month period. The project comprised educating staff including nurses, nursing assistants, supervisors, and care managers, and implementation of the head positioner from July 2018 to December 2018. Staff from the SICU and CVICU, a step-down unit, and a neurological ICU were also educated on the use of a fluidized positioner, because patients were transferred to these units when stable. All patients who underwent craniotomy surgery were placed on the fluidized positioner post-operatively until immobilization and off-loading were no longer required. During the initial 6-month evaluation period, no new pressure injuries (PIs) or incisional trauma occurred in the 8 patients. The economic impact to treat 1 hospital-acquired unstageable PI was estimated at $78,722. Because no new occipital PIs occurred in the 8 patients placed on the fluidized head positioner, the hospital potentially saved $629,776. The authors concluded that the findings from the project suggested that implementation of a fluidized positioner could re-distribute pressure to the occiput, off-load craniotomy incision sites, and prevent PIs. These preliminary findings need to be validated by well-designed studies.

Fluidized Positioner for the Prevention of Skin and Mucosal Damage in Patients with COVID-19

Singh and colleagues (2020) noted that patients admitted to the ICU are at a high risk for developing PIs. A patient requiring multi-organ support is at a higher risk for PIs related to immobility, sedation, vasopressors, and hypoxia. To mitigate PIs, the authors’ hospital employs a bundle approach to prevent skin injury. However, despite efforts to prevent PIs, these investigators found that their patients in the ICU with the diagnosis of COVID-19 went on to develop significant pressure and mucosal injuries. This was a case-series study of 4 patients diagnosed with COVID-19 who developed significant skin and mucosal injuries during their ICU admissions in March 2020. These researchers found that patients developed skin conditions that were initially thought to be deep-tissue injuries (DTIs) early in the admission. The DTIs progressed over the course of the admission in the ICU and evolved to thick adherent eschar that appeared to be unstageable PIs, which extended beyond the soft tissue directly over the bony prominence. These investigators also found that skin damage to the mucosa of the nares, tongue, lips, and urethra presented first as inflammation and then progressed to thick eschar. Despite maximum pressure relief with the use of a pressure-relieving turn and position system, bordered foam dressings, fluidized positioners, specialty beds, and leadership support for twice-weekly skin checks, these COVID-19 patients developed extensive skin damage across the fleshy portion of the buttocks and on the mucosa of the nares, tongue, lips, and urethra during minimal exposure to pressure. The authors concluded that although the initial presentation of the skin damage appeared to be related to pressure, the extent of the skin damage suggested a vascular inflammatory process beyond skin damage related to pressure.

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Appendix

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 member'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.

Definitions and Instructions Relevant to Interpretation of This Policy

1. Pressure Ulcer Staging

   The staging of pressure ulcers used in this policy is as follows:

   Table: Staging of Pressure Ulcers

   Stages	Descriptions
   Stage I	Non-blanchable erythema of intact skin
   Stage II	Partial thickness skin loss involving epidermis and/or dermis
   Stage III	Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
   Stage IV	Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures

2. Group 1 Support Surfaces

   The following are considered group 1 support surfaces: pressure pads for mattresses, non-powered pressure reducing mattresses, and powered pressure reducing mattress overlay systems. Each of the support surfaces described below is considered medically necessary when criteria for group 1 support surfaces are met.

   Pressure pads for mattresses are non-powered pressure-reducing mattress overlays. These devices are designed to be placed on top of a standard hospital or home mattress. Pressure pads for mattresses with the following features are considered medically necessary when criteria for group 1 support surfaces are met:

   • A gel mattress overlay is considered a group 1 support surface only if the gel or gel-like layer has a height of 2 inches or greater.
   • A water mattress overlay is considered a group 1 support surface if it has a filled height of 3 inches or greater.
   • An air mattress overlay has interconnected air cells that are inflated with an air pump.  Only air mattress overlays with a cell height of 3 inches or greater are considered group 1 support surfaces.
   • Only foam mattress overlays with all of the following features are considered group 1 support surfaces:
      
     
     • Base thickness of 2 inches or greater and peak height of 3 inches or greater if it is a convoluted overlay (e.g., eggcrate) or an overall height of at least 3 inches if it is a non-convoluted overlay; and
     • Durable, waterproof cover; and
     • Foam with a density and other qualities that provide adequate pressure reduction.

     Non-powered pressure reducing mattresses with the following features are considered medically necessary when criteria for a group 1 support surface are met:

   • Only foam mattresses with all of the following features are considered group 1 support surfaces:

     • A foam height of 5 inches or greater; and
     • Can be placed directly on a hospital bed frame; and
     • Durable, waterproof cover; and
     • Foam with a density and other qualities that provide adequate pressure reduction.

   • Only air, water, or gel mattresses with all of the following features are considered group 1 support surfaces:

     • A height of 5 inches or greater of the air, water, or gel layer (respectively); and
     • Can be placed directly on a hospital bed frame; and
     • Durable, waterproof cover.

   Powered pressure reducing mattress overlay systems (alternating pressure or low air loss) are considered group 1 support surfaces only if when all of the following features are present:

   1. An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the overlay; and
   2. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays), and air pressure provide adequate patient lift, reduce pressure, and prevent bottoming out; and
   3. Inflated cell height of the air cells through which air is being circulated is 2.5 inches or greater.

   Examples of group 1 support surfaces include the WAFFLE Brand Air Insert With Foam Base, the WAFFLE Brand Static Air Mattress Overlay, and the Aquatherm Tender-Clous Static Air System.

3. Group 2 Support Surfaces

   The following are considered group 2 support surfaces: powered pressure reducing mattresses, semi-electric or total electric hospital beds with powered pressure reducing mattresses, powered pressure reducing mattress overlays and underlays, advanced non-powered pressure reducing mattresses, and advanced non-powered pressure reducing mattress overlays and underlays. Each of the support surfaces described below is considered medically necessary when criteria for group 2 support surfaces are met.

   A powered pressure reducing mattress (alternating pressure low air loss, or powered flotation without air loss) is considered a group 2 support surface only when all of the following features are present:

   1. A surface designed to reduce friction and shear; and
   2. An air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress; and
   3. Can be placed directly on a hospital bed frame; and
   4. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattress), and air pressure to provide adequate patient lift, reduce pressure, and prevent bottoming out; and
   5. Inflated cell height of the air cells through which air is being circulated is 5 inches or greater.

   Semi-electric or total electric hospital beds with fully integrated powered pressure-reducing mattresses that have all of the features described above are considered group 2 support surfaces.

   An advanced non-powered pressure-reducing mattress overlay is considered a group 2 support surface when all of the following features are present:

   1. A surface designed to reduce friction and shear; and
   2. Documented evidence to substantiate that the product is effective for the treatment of conditions described by the medical necessity criteria for group 2 support surfaces; and
   3. Height and design of individual cells provide significantly more pressure reduction than group 1 overlay and prevent bottoming out; and
   4. Total height of 3 inches or greater.

   A powered pressure reducing mattress overlay/underlay (low air loss, powered flotation without low air loss, or alternating pressure) is considered a group 2 support surface when all of the following features are present:

   1. A surface designed to reduce friction and shear; and
   2. An air pump or blower that provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the overlay; and
   3. Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure overlays/underlays), and air pressure to provide adequate patient lift, reduce pressure and prevent bottoming out; and
   4. Inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater.

   An advanced non-powered pressure-reducing mattress is considered a group 2 support surface when all of the following features are present:

   1. A surface designed to reduce friction and shear; and
   2. Can be placed directly on a hospital bed frame; and
   3. Documented evidence to substantiate that the product is effective for the treatment of conditions described by the medical necessity criteria for group 2 support surfaces; and
   4. Height and design of individual cells that provide significantly more pressure than a group 1 mattress and prevent bottoming out; and
   5. Total height of 5 inches or greater.

   Examples of group 2 pressure reducing support surfaces include the ROHO Dry Flotation Mattress System, the Flexicare Low-Air-Loss Bed, the Mediscus Air Support Therapy, the Grand Dyna-Care Alternating Pressure-Relief Seat Pad, and the Aquatherm Deluxe Alternating Pressure Pad.

4. Group 3 Support Surfaces

   Group 3 support surfaces include air-fluidized beds. An air-fluidized bed uses warm air under pressure to set small ceramic beads in motion which simulate the movement of fluid. When the member is placed in the bed, his body weight is evenly distributed over a large surface area, which creates the sensation of “floating.” Air-fluidized beds are considered medically necessary when the criteria for group 3 support surfaces are met.

   Note that pressure-reducing support surfaces containing multiple components are categorized according to the clinically predominant component (usually the topmost layer of a multi-layer product).

   A support surface that does not meet the characteristics specified in the support surface policy will usually be considered not medically necessary.

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References