Description:
An enclosed bed system is a specialized bed that has been manufactured or customized with additional protection and/or enclosure components. These beds can be fully or partially enclosed with zippered mesh panels or fabricated with wooden or metal side panels or side rails with interior padding that may only be opened from the outside and include other safety components. Enclosed beds or bed frames with protective components are used for individuals who are at risk from injuring themselves while in bed. Because an enclosed bed system is very restrictive, use of the system with protective components should be considered only after all available and less restrictive alternatives have been unsuccessful in maintaining the safety of the individual. The ideal approach is to address the underlying medical and/or behavioral issues that increase the risk of harm. Protective or enclosure beds generally are medically necessary for individuals who are prone to harm from injury by exiting the bed unsafely and are unable to use a less intensive and restrictive alternative. The use of an enclosed bed and the risk of sensory deprivation must be part of the overall plan of care for a child or adult at risk for self-injury.

Policy:

Protective or enclosure beds may be considered MEDICALLY NECESSARY for children and adults with a disease or medical condition that increases risk of injury and/or make them especially susceptible to harm from injury by exiting the bed unsafely and are unable to use a less intensive alternative when ALL of the following criteria must be met:

1. There is cognitive and communication impairment and ONE of the following conditions

a. Cerebral Palsy (moderate to severe); OR

b. Neurological disorders causing disorientation or vertigo; OR

c. Developmental delays; OR

d. Seizure disorder (daily); OR

e. Severe behavioral disorder; OR f. Traumatic Brain Injury (TBI); OR

g. Uncontrolled perpetual movement related to diagnosis.

    AND

    2. Submission of medical necessity documentation for protective or enclosed bed system, including:

a. Age of member; AND

b. Description of medical condition and clinical need for a safety enclosure; AND

c. Evidence of proven safety risk including documentation of history of behavior involving unsafe mobility and history of injuries or risk that have occurred prior to this request; AND

d. All appropriate less intensive alternatives that have been tried and have proven unsuccessful including but not limited to the following: bed tent or canopy attachment,  bed rails, bed rail protectors, padding added to ordinary beds, mattress placed on floor, helmets, removal of all safety hazard, monitors, other child protection devices, medications to address seizures and/or correct behaviors; environmental, sensory and/or behavioral modifications (including door and window locks, baby monitor devices); AND

e. Name and model of protective or enclosure bed with a valid HCPCS code, (miscellaneous durable medical equipment [DME] codes, such as E1399 will NOT be accepted); AND

f. A home evaluation from a qualified occupational or physical therapist (or other clinician) that is comprehensive and specific to the individual that documents ALL of the following:

• A comparative evaluation of various enclosed beds that explains the rationale and clinical need for the requested enclosed bed and components; AND

• Education to the caregivers regarding the use of the enclosed bed; AND

• Evaluation of trials of less restrictive strategies.

The Technology Hub addition to the enclosed bed system is considered NOT MEDICALLY NECESSARY. 

Enclosed bed systems are considered NOT MEDICALLY NECESSARY for ANY of the following:

1. Children who are under the age of 3
2. For adults with confusion or dementia 
3. For caregiver need or convenience 

References:

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

Index

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2024 Forward 

04/17/2024 NEW POLICY