Recent Changes to Medicare Requirements
Unlike most durable medical equipment, Medicare now requires prior authorization for advanced therapeutic surfaces such as low air loss mattresses, alternating pressure mattresses, and air fluidized beds (technically called “Group 2 Support Surfaces”). This change took effect in 2024 and represents a significant shift in how these items are approved for coverage.
What Items Need Prior Authorization?
- Low Air Loss Mattresses
- Alternating Pressure Mattresses
- Air Fluidized Beds
- Advanced Non-powered Pressure Reducing Surfaces
Processing Timeframes
Standard Requests
- Medicare has 5 business days to review
- Plan accordingly during discharge planning
- Allow time for possible additional documentation requests
Expedited Requests
- Medicare processes in 2 business days
- Must clearly document why delay would be life-threatening
- Examples of successful expedited justification:
- “Patient has large stage 4 sacral wound with exposed bone requiring immediate specialized surface to prevent osteomyelitis”
- “Post-surgical flap patient requires immediate specialized surface to prevent flap failure”
- “Extensive trunk wounds with significant drainage requiring immediate moisture management to prevent sepsis”
Required Documentation
Written Order Requirements
Must be completed before equipment delivery:
- Patient’s name
- Detailed description of equipment
- Prescriber’s NPI
- Signature and date
Clinical Documentation
Must demonstrate ONE of these situations:
- Multiple Stage 2 Pressure Ulcers
- On trunk or pelvis
- Failed to improve over past month despite:
- Basic support surface
- Regular assessments
- Turning/positioning
- Wound care
- Moisture management
- Nutritional support
- Stage 3 or 4 Pressure Ulcers
- Large or multiple ulcers
- Located on trunk or pelvis
- Recent Surgical Cases
- Myocutaneous flap or skin graft for pressure ulcer
- Within past 60 days
- Using advanced surface currently
- Recent discharge (within 30 days)
Documentation Tips
- Wound care notes are excellent sources
- Include wound measurements and photos
- Document failed previous interventions
- Include comprehensive care plan
- Show why basic surfaces are insufficient
Process Tips
- Start authorization process early in discharge planning
- Submit all documentation at once
- Clearly mark requests as “Expedited” when appropriate
- Include detailed clinical justification
- Have backup discharge plan in case of denial
Important Notes
- Suppliers may request your documentation
- No charge permitted for providing records
- Document both equipment need and comprehensive wound care
- Include other interventions like:
- Nutrition optimization
- Blood glucose control
- Pressure relief
- Smoking cessation
- Wound care
- Advanced dressings
