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LCD - Low Air Loss

Coverage Summary

Written Order Prior to Delivery

Must meet 1, 2, or 3:

  1. The patient has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02-707.05) which have failed to improve over the past month, during which time the patient has been on a comprehensive ulcer treatment program.
  2. The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02-707.05)
  3. The patient had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (ICD-9 707.02 -707.05), 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.

Order Requirements

  • DME Order Form
  • Dr. must be PECOS registered for all Medicare orders.

  1. Patient's Name
  2. Detailed description of specific equipment being ordered
  3. Qty to be dispensed
  4. Ordering Physician’s NPI
  5. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  6. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  7. Start date of the order – if different than signature date.

Coverage Detail

Patient MUST meet at least one of the following criteria (1, 2 or 3):

1. The patient has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02-707.05) 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

2. The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02-707.05),

3. The patient had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days (ICD-9 707.02 -707.05), 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

Note:

  • If the patient 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.
  • Continued use of a support surface is covered until the ulcer is healed, or if healing does not continue, there is documentation in the medical record to show that: (1) other aspects of the care plan are being modified to promote healing, or (2) the use of the group 2 support surface is reasonable and necessary for wound management.
  • For continued insurance coverage, progress notes must be provided on a monthly basis.