GROUP 2 – Powered or non-powered pressure reducing mattress

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Valid detailed written Physician Order/Statement of Medical Necessity

Chart notes documenting that the beneficiary meets ALL coverage criteria in one of the situations noted below AND completion of Statement of Medical Necessity, Group 2.” See attached

1) Beneficiary has multiple stage II ulcers located on trunk or pelvis which have failed to improve over the past month during which time the beneficiary has been on a comprehensive ulcer treatment program for at least the past month (minimum 30 days) which has included all the following:

a) Use of an appropriate group 1 support surface; and

b) Regular assessment by a nurse, physician, or other licensed healthcare practitioner (usually at least weekly for a patient with a stage III or IV ulcer); and

c) Appropriate turning and positioning; and

d) Appropriate wound care; and

e) Appropriate management of moisture/incontinence; and

f) Nutritional assessment and intervention consistent with overall plan of care; OR

2) Beneficiary has large or multiple stage III or IV pressure ulcer(s) on trunk or pelvis

3) Beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the last 60 days and the patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).