Safety Items
Number: 0623
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses 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 alarms), bed rails, belts, car seats (e.g., Carrie Car Seat, Columbia Orthopedic Positioning Seat, Gorilla Postural Seat, Snug Seat, Traveller Plus seat, Special Tomato MPS Car Seat), Embrace2 seizure monitoring watch, Exersides Refraint System (upper extremity medical tubing/lines enclosure or covering device, restricts elbow range of motion), fall detection systems, fire extinguishers, first aid kits, grab bars, harnesses, hearing protectors (ear plugs; e.g., DB blockers), helmetsFootnote1* (e.g., Danmar soft shell helmet), knee and elbow pads, restraints, safety goggles, service dogs, smoke and carbon monoxide detectors, telephone alert systems, and vehicular restraint systems (e.g., EZ-On Vest).
-
Policy Limitations and Exclusions
Please check benefit plan descriptions.
-
Aetna standard benefit plans
Most standard Aetna benefit plans specifically exclude coverage of safety items. 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.
-
Aetna standard HMO-based plans
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.
-
Aetna non-standard plans
For non-standard plans that do not exclude coverage of safety items, Aetna covers safety items for members with diseases or medical conditions that: place them at increased risk of injury; and/or 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). See benefit plan descriptions. Safety items that are normally of use in the absence of illness or injury do not meet Aetna's definition of covered DME. This would include car safety seats, fire extinguishers, first aid kits, knee and elbow pads, safety goggles, and smoke and carbon monoxide detectors.Under non-standard 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.
Under non-standard plans that do not exclude safety items, grab bars that are affixed to a wall or floor, such as around the bathtub or toilet, are not covered under the standard exclusion for addition or alternations to a home, workplace or other environment. Please see benefit plan descriptions.
Under non-standard plans that do not exclude safety items, hospital bedside rails, hospital bed safety enclosure framesFootnote2**, and enclosed hospital-grade pediatric cribs would be considered medically necessary for persons with neurocognitive or physical disabilities that place them at increased risk for falling from the bed. Under these plans, safety equipment (e.g., belt, harness or vest) would be considered medically necessary for persons with neurocognitive or physical disabilities that place them at increased risk for falls. Restraints (body, chest, wrist or ankle) and vehicular restraint systems (e.g., EZ-On Vest) would be considered medically necessary for persons with neurocognitive or physical disabilities that place them increased risk of injury.
Under nonstandard plans that do not exclude safety items, safety and athletic prescription lenses and frames would be excluded from coverage under the standard vision exclusion. Please check benefit plan descriptions.
-
Telephone alert systems
Telephone alert systems are not covered because they 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. Telephone alert systems are also known as emergency medical alert button systems (e.g., AlertOne, Lifeline, etc.), Please check benefit plan descriptions for details.
Footnote1* 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 0379 - Cranial Remodeling.
Footnote2** For coverage of hospital bed safety enclosure frames that are part of a medically necessary hospital bed, see CPB 0543 - Hospital Beds and Accessories.
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.
-
-
Related Policies
- CPB 0379 - Cranial Remodeling
- CPB 0429 - Bathroom and Toilet Equipment and Supplies - for grab bars that are affixed to a wall or floor, such as around the bathtub or toilet
- CPB 0543 - Hospital Beds and Accessories - for hospital bedside rails, hospital bed safety enclosure frames and enclosed hospital-grade pediatric cribs
References
The above policy is based on the following references:
- 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.
- Anderson O, Boshier PR, Hanna GB. Interventions designed to prevent healthcare bed-related injuries in patients. Cochrane Database Syst Rev. 2012;(1):CD008931.
- Everitt V, Bridel-Nixon J. The use of bed rails: Principles of patient assessment. Nurs Stand. 1997;12(6):44-47.
- SleepSafe Beds, LLC. The SleepSafe [website]. Callaway, VA; SleepSafe Beds; 2008. Available at: http://www.sleepsafebed.com/. Accessed August 5, 2008.
- Thompson DC, Rivara FP, Thompson R. Helmets for preventing head and facial injuries in bicyclists. Cochrane Database Syst Rev. 1999;(4):CD001855.
- 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.
- 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.
- Werner P, Koroknay V, Cohen-Mansfield J. To use physical restraints or not. J Am Geriatr Soc. 1997;45(2):253.
- 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.
