Is a dynamic mattress overlay for treatment of pressure sores that can be placed directly on a hospital bed frame and billed separately.

This item is covered if the following is met:

1. Criteria 1, 2 and 3, or
2. Criterion 4, or
3. Criteria 5 and 6.
   1. Multiple Stage II pressure ulcers located on the trunk or pelvis.
   2. Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate Group I Support Surface.
   3. The ulcers have worsened or remained the same over the past month.
   4. Large or multiple Stage III or IV pressure ulcer(s) (see below) on the trunk or pelvis.
   5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days). Coverage is generally limited to 60 days from the date of surgery.
   6. The patient has been on a Group II or III Support Surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).
      • Stage 1: Nonblanchable erythema of intact skin
      • Stage II: Partial thickness skin loss involving epidermis and/or dermis
      • Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
      • Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis damage to muscle, bone or supporting structures

A physician's written prescription/order must be furnished to the supplier prior to delivery (WOPD). Monthly assessments must be conducted for continued coverage. These assessments can be conducted and documented by a home health agency.