Pressure Reducing Support Surfaces (CPB 0430, reviewed 2026-07-10)

By 2026-07-10: Billing and authorization teams must implement comprehensive prior authorization requirements for all pressure-reducing support surface claims submitted to Aetna. (1) Update authorization software to require documentation of: for Group 1 surfaces - complete immobility OR limited mobility plus one criterion (pressure ulcer, nutritional status, incontinence, sensory impairment, or circulatory compromise); for Group 2 surfaces - multiple Stage II ulcers with prior Group 1 use for ≥1 month with worsening/unchanged status, OR Stage III/IV ulcers, OR recent flap/graft (≤60 days), OR discharge from hospital/facility within 30 days; for Group 3 air-fluidized beds - Stage III/IV ulcer on trunk/pelvis, bedridden/chair-bound status, would require institutionalization without bed, documented physician evaluation within 1 week of order, trained caregiver availability, physician monthly recertification, and conservative treatment failure for ≥1 month. (2) Require providers to submit written physician orders with clinical justification and comprehensive care plan documentation (turning/positioning, wound care, nutritional assessment, incontinence management, weekly practitioner assessment). (3) Implement 'bottoming out' testing requirements - claims must document pressure surface prevents hand palpation of bony prominences in supine (flat and 30° elevated) and side-lying positions. (4) Update denial reason codes for claims lacking required documentation or not meeting criteria. (5) Train authorization staff on experimental/investigational determinations - mark claims as denied if criteria unmet due to insufficient peer-reviewed evidence. (6) Flag air-fluidized bed contraindications (inadequate electrical/structural support, unwilling caregiver, pulmonary disease, wet wound dressing needs) for automatic review. Failure to implement these controls will result in claim denials for non-compliant submissions.