A Group 1 mattress overlay or mattress (E0181-E0189, E0196-E0199, and A4640) is covered if one of the following three criteria are met:

1. The patient is completely immobile - i.e., patient cannot make changes in body position without assistance, or
2. The patient has limited mobility - i.e., patient cannot independently make changes in body position significant enough to alleviate pressure and at least one of conditions A-D below, or
3. The patient has any stage pressure ulcer on the trunk or pelvis and at least one of conditions A-D below. Conditions for criteria 2 and 3 (in each case the medical record must document the severity of the condition sufficiently to demonstrate the medical necessity for a pressure reducing support surface):

   a. Impaired nutritional status
   b. Fecal or urinary incontinence
   c. Altered sensory perception
   d. Compromised circulatory status

Patients needing pressure reducing support surfaces should have a care plan which has been established by the patient's physician or home care nurse, which is documented in the patient's medical records, and which generally should include the following:

1. Education of the patient and caregiver on the prevention and/or management of pressure ulcers.
2. Regular assessment by a nurse, physician, or other licensed healthcare practitioner.
3. Appropriate turning and positioning.
4. Appropriate wound care (for a stage II, III, or IV ulcer).
5. Appropriate management of moisture/incontinence.
6. Nutritional assessment and intervention consistent with the overall plan of care.