HFSMedical ProvidersMedical Prior Approval CriteriaPediatric Specialty Beds Criteria

Pediatric Specialty Beds Criteria

Description:  

Pediatric specialty beds (e.g., infant/child bed enclosures, canopy bed or safety enclosure frame) are hospital grade beds with various added safety enclosures such as a canopy and/or mesh enclosure.

Specific Indications:

Generally, confinement is not medically necessary nor is it the least costly way of preventing injuries as a result of seizure activity or self injurious behaviors such as head banging, rocking, etc.

In addition, some enclosed beds have been determined by the U.S. Food and Drug Administration (FDA) to pose significant safety risk.

Due to the restrictive nature and extreme confinement of specialty beds that can result in issues of sensory deprivation and potential for overuse, this type of equipment will be considered necessary only in the presence of the most extreme medical conditions.

The best approach is to address the underlying medical and/or behavioral issues first.  It must be shown that other, less costly methods have been attempted and have failed to effectively treat the problem.

These criteria will be used for all specialty bed coverage considerations, and each request will be evaluated individually to determine whether or not the medical justification exists to grant an approval.

Approval Criteria:

For approval consideration of pediatric specialty beds, the child must meet all of the following six criteria:

1. Child must have one or more of the following diagnoses/medically necessary criteria:

  • Traumatic brain injury; 
  • Cerebral palsy - moderate to severe;
  • Seizure disorder with daily seizure activity, characterized  by loss of consciousness or lack of awareness to surroundings;
  • Pervasive developmental disorder;
  • Psychiatric, neurological or metabolic diagnosis with documented risk of self injury;
  • Severe behavioral disorder

 

2. There is cognitive and communication impairment.

3. There is documentation of medical necessity that includes at least one of the following:

  • Daily seizure activity, as defined above;
  • Uncontrolled perpetual involuntary movement related to a medical diagnosis;
  • Self injurious behavior, such as head banging, where a helmet was tried and not successful.

 

4. There is evidence of a safety risk that includes at least one of the following:

  • The child demonstrates unsafe mobility that will put the child at risk for serious injury, not just a possibility of injury (such as climbing out of bed)
  • The child has balance problems or vertigo
  • The child has history of injury that has occurred prior to this request

 

5. Documented use of more cost effective alternatives and the outcomes including but not limited to:

  • Positional aids and side rails with padding around the regular bed
  • Alternative bedding, such as moving the mattress to the floor with surrounding padding
  • Management of seizure disorder
  • Pharmacotherapy
  • Helmet for head protection
  • Behavioral therapy
  • Environmental assessment and removal of safety hazards and use of appropriate child protective devices
  • Use of portable monitoring devices, such as a baby monitor to listen in on the child’s activities

 

6. In order to assess medical necessity for the pediatric specialty bed, sufficient information must be furnished by the child’s physician and accompany the prior approval request. Necessary documentation includes a letter of medical necessity that includes at least the following:

  • Child’s medical, psychiatric, neurological, metabolic, and/or behavioral diagnosis 
  • The child’s special needs that are a result of the diagnosis/condition that shows a medical need for a specialty bed
  • The specific name, type, and bed model that addresses each of the concerns with specific requirements such as full safety rails,  specific height required for safety, or the necessity of articulation to raise the head or feet of the child in order to feed, medicate, or provide mobility
  • Documentation as to how the child’s current bed or crib or modifications to the bedroom fails to address the clinical need. Include, if applicable, does the child have the capacity to climb
  • Assessment of the child’s physical status, to include an Assessment of Gross Motor Function Classification System Expanded and Revised (GMFCS – E&R)
  • Current  and previous treatment modalities, including an explanation why these modalities were not successful
  • Assessment of cognitive function including developmental age equivalent for motor function, cognitive function, and habilitation potential
  • Detailed history of safety issues including incidence and resulting in injury 

 

7. Please also provide the following:

  • List of all caregivers in the home that includes all family, medical professionals, and home aides. It should also include how many hours per day, during what times of the day, and the number of days per week these caregivers are available.
  • Is the child in school/daycare, and if so, provide the number of days per week and number of hours a day.

Non Covered

  • Beds sold as traditional furniture including adjustable beds that are not manufactured as durable medical equipment.
  • Bed accessories, including but not limited to bed tables, bed linens, and pillows.
  • Enclosed beds for children with 24 hours per day paid caregivers
  • Specialty beds for the convenience of the caregiver.

According to the U.S. FDA some pediatric specialty beds are considered experimental and investigational or recalled (due to significant safety risks) and therefore are not covered.

Review Process:

  1. Specialty pediatric beds require prior authorization. The reviewer determines if there is sufficient clinical information and a written, signed, and dated physician order. If the case does not meet the established criteria, and denial of the request is recommended by the reviewer the case shall be referred to a staff physician and the supervisor of the Prior Approval Unit for review.
  2. The reviewer completes the review process and denies or approves the request in accordance with HFS policy and directives.
  3. The decision to approve or deny a prior approval request for a pediatric specialty bed is not intended as a treatment recommendation or as treatment guidance.

References:

  1. Minnesota Department of Human Services Provider Manual: Bed Enclosure: 
  2. Anthem Clinical UM Guideline; Hospital Beds and Accessories, Guideline # CG-DME-15;
  3. Cigna HealthCare Coverage Position Hospital Beds and Accessories, Coverage Position # 0273, revised 1/15/08.
  4. U.S. Food and Drug Administration, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Care: The Facts, 2/28/08.
  5. North Carolina Department of Health and Human Services, Office of the Controller Special Bulletin Purchase of Medical Care Services, Appendix A; Special Justification Requirements for Certain Types of Adaptive and Assistive devices, Specialized Pediatric Beds, July 2005.
  6. Guidance/Guidance/Manuals (pdf),  Section 110.1.
  7. UPMC Health Plan Policy and Procedure Manual, 2013

 


Medical Prior Approval Criteria

 

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