A doctor can write a prescription for an adjustable bed, but this process is strictly governed by medical criteria and is treated as a request for Durable Medical Equipment (DME). In this context, the adjustable bed is viewed as a medical device required for a patient’s treatment plan, not a luxury consumer item. The prescription serves as the initial, formal step in establishing “medical necessity” to seek coverage from insurance payers like Medicare.
Defining Medical Necessity for Adjustable Beds
To qualify for coverage, the adjustable bed must serve a therapeutic purpose that a standard bed cannot provide. Medical necessity is established when the bed’s features are required to manage a severe health condition or prevent further injury. This includes conditions where the patient requires body positioning, not feasible with ordinary bedding like pillows or wedges, to alleviate pain or promote proper body alignment.
Qualifying conditions often involve severe breathing problems, such as chronic pulmonary disease or congestive heart failure, necessitating head elevation over 30 degrees to improve respiratory function. Circulatory issues, like severe edema, may require specialized positioning to elevate the legs and manage blood flow. The bed may also be necessary if a condition like severe arthritis, paraplegia, or a hip fracture makes getting in and out of a traditional bed difficult or unsafe. In these cases, the adjustable height feature facilitates safer transfers to a wheelchair or standing position.
The Specifics of Required Documentation
A simple note from a physician is generally insufficient to secure coverage for an adjustable bed. The formal process requires a detailed written order, often called a Certificate of Medical Necessity (CMN), which justifies the equipment. This documentation mandates that the prescribing physician clearly articulate the diagnosis using specific codes and explain why the patient meets the criteria for a hospital bed.
The CMN must detail the exact features required, such as whether a fully electric or semi-electric model is needed, and if accessories like trapeze bars or specialized mattresses are necessary. The doctor must certify that the medical condition requiring the bed is expected to last for at least one month and indicate the estimated length of need. Crucially, the physician must sign and date the form, attesting that they had a face-to-face visit with the patient within six months of placing the order.
Insurance Coverage Pathways for Durable Medical Equipment
Adjustable beds meeting medical necessity criteria are classified as Durable Medical Equipment (DME) under major insurance programs. Medicare Part B is the primary pathway for coverage, covering certain adjustable beds that function as a hospital bed when prescribed for home use. Medicare distinguishes between consumer-grade adjustable bases and medical-grade hospital beds, generally excluding those primarily for comfort or convenience.
Original Medicare Part B typically covers 80% of the Medicare-approved amount for the DME after the annual deductible is met. Coverage may be provided through rental or purchase, often dictated by the condition’s permanence and the equipment’s expected lifespan. Private insurance plans and Medicare Advantage (Part C) generally follow similar DME guidelines but may require pre-authorization. Only the features directly tied to the patient’s medical need will be approved for coverage.
Working with Suppliers and Cost Considerations
Once the prescription and Certificate of Medical Necessity are complete, the patient must obtain the bed from a supplier enrolled in Medicare or their specific insurance network. Medicare only covers equipment provided by suppliers who accept assignment, meaning they agree to accept the Medicare-approved amount as full payment. It is advisable to ask the prescribing doctor for a list of trusted suppliers who have worked with the practice before.
The patient remains responsible for the remaining 20% coinsurance of the approved amount, along with any unmet Part B deductible. If the claim is initially denied by the insurer, the patient has the right to appeal the decision, often with the assistance of the DME supplier. For individuals with a low income, Medicaid or state waiver programs may provide additional financial assistance to cover the remaining costs.