GROUP 1 – MATTRESS OVERLAY OR MATTRESS

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Valid detailed Physician Order/Statement of Medical Necessity as outline above

Chart notes documenting the following AND completion of “Statement of Medical Necessity, Group 1.” See attached.

Mattress overlay or mattress is covered if ONE of the three criteria is met:

- The beneficiary is completely immobile – i.e., beneficiary cannot make changes in body position without assistance; OR

- The beneficiary has limited mobility – i.e., beneficiary cannot independently make changes in body position significant enough to alleviate pressure and at least one of the following:

Impaired nutritional status; or

Fecal or urinary incontinence; or

Altered sensory perception; or

Compromised circulatory status

OR

- The beneficiary has any stage pressure ulcer on the trunk or pelvis and at least one of the following:

Impaired nutritional status; or

Fecal or urinary incontinence; or

Altered sensory perception; or

Compromised circulatory status