Reasons for Non-Affirmed Prior Authorization for Group 2 Pressure Reducing Support Surfaces
The order was missing or incomplete.
The Standard Written Order (SWO) submitted with the prior authorization request for the must include the following:
- Beneficiary's name or Medicare Beneficiary Identifier (MBI)
- Order Date
- General description of the item
- The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
- For equipment – In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
- Treating Practitioner Name or NPI
- Treating practitioner's signature
The documentation contains amendments, corrections, and/or delayed entries that do not comply with accepted record keeping principles.
Documents containing amendments, corrections or addenda must:
- Clearly and permanently identify any amendment, correction, or delayed entry as such, and
- Clearly indicate the date and author of any amendment, correction, or delayed entry, and
- Clearly identify all original content, without deletion
Refer to Section 10 of the Supplier Manual Chapter 3 – Supplier Documentation
for additional information.
The documentation submitted did not confirm that the below coverage criteria were met.
A group 2 support surface is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
- The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis (refer to the "ICD-10 Codes that are Covered" section in the Pressure Reducing Support Surfaces – Group 2 – Policy Article (A52490)
for applicable diagnoses) which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
- Use of an appropriate group 1 support surface, and
- Regular assessment by a nurse, physician, or other licensed healthcare practitioner, and
- Appropriate turning and positioning, and
- Appropriate wound care, and
- Appropriate management of moisture/incontinence, and
- Nutritional assessment and intervention consistent with the overall plan of care
- The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (refer to the "ICD-10 Codes that are Covered" section in the Pressure Reducing Support Surfaces – Group 2 – Policy Article (A52490) for applicable diagnoses) – This means documenting more than one (1) stage III or IV pressure ulcer on the trunk or pelvis. In addition, coverage is also considered for a single, large pressure ulcer, with "large" traditionally defined as >8 cm2 in size. Medical review clinicians, when considering coverage of large ulcers, take into account whether undermining and/or tunneling are present, the anatomic location on the body and the size of the beneficiary.
- The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (refer to the "ICD-10 Codes that are Covered" section in the Pressure Reducing Support Surfaces – Group 2 – Policy Article (A52490) for applicable diagnoses), and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days
If the beneficiary 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. The support surface provided for the beneficiary should be one in which the beneficiary does not "bottom out".
When a group 2 surface is covered following a myocutaneous flap or skin graft, coverage generally is limited to 60 days from the date of surgery.
Refer to Pressure Reducing Support Surfaces – Group 2 Local Coverage Determination (LCD) L33642 and Policy Article A52490.
The medical record documentation was not authenticated (handwritten or electronic) by the author.
For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author.
- The method used shall be a handwritten or electronic signature. Additional information regarding signature requirements is in the CMS Fact Sheet: Complying with Medicare Signature Requirements.
- A signature attestation may be submitted along with unsigned medical records to fulfill the signature requirements.
Refer to the CMS MLN Fact Sheet: Complying with Medicare Signature Requirements
Claim history indicates same or similar equipment.
The reasonable, useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, DME MACs determine the reasonable, useful lifetime of equipment, but in no case can it be less than five years.
Check for same or similar equipment through the Interactive Voice Response (IVR) or myCGS.
Refer to the DME myCGS User Manual for information on checking same or similar.
Revised: 03.05.24
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