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Pressure Reducing Support Surfaces (CPB 0430, reviewed 2026-07-10)
Effective date
Not stated in the notice
Identified
Aug 13, 2026
Summary
Aetna's Clinical Policy Bulletin 0430 covers pressure-reducing support surfaces as durable medical equipment and sets separate criteria for group 1 mattresses and overlays, group 2 alternating pressure and low air loss surfaces, and group 3 air-fluidized beds. Group 2 surfaces are medically necessary when the member meets criteria such as having multiple stage II pressure ulcers on the trunk or pelvis after a comprehensive ulcer treatment program, having large or multiple stage III or IV ulcers on the trunk or pelvis, or having had a recent myocutaneous flap or skin graft. A support surface that does not prevent bottoming out is considered not medically necessary, and ordinary consumer-grade air mattresses are not covered because they do not meet Aetna's contractual definition of durable medical equipment.
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What to do
Action · 8 steps
01Before billing a support surface in this policy, confirm that a completed Standard Written Order was communicated to the supplier, because a claim billed without a completed SWO shall be denied as not medically necessary.
02The SWO must include the member's name or identification number, the order date, a general description of the item (a HCPCS code, a HCPCS code narrative, or a brand name and model number), each concurrently ordered option, accessory or upgrade that is separately billed listed separately, each item's HCPCS code and quantity, and the treating practitioner's name, NPI and signature.
03A treating practitioner means a physician (MD or DO), physician assistant, nurse practitioner or clinical nurse specialist, and a prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist or occupational therapist is not considered a treating practitioner.
04A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.
05The member's medical record must contain information that supports medical necessity and substantiates any supplier-prepared statement or practitioner attestation, because an order, a supplier statement or an attestation by itself is not sufficient, and records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves.
06For air-fluidized beds, confirm the attending physician's written order follows a comprehensive assessment generally performed within a week before therapy starts, and that the physician reevaluates and recertifies the need for the bed monthly.
07Confirm the member has a documented care plan established by the physician and home care nurse that generally includes management of moisture and incontinence, turning and positioning, wound care, education of the member and caregiver, nutritional assessment and intervention, and regular assessment by a licensed practitioner.
08Do not bill fluid immersion simulation systems such as Dolphin FIS for home use, because the policy considers them institutional equipment that is inappropriate for home use.
Codes mentioned
A4640E0181E0182E0183E0184E0185E0186E0187E0188E0189E0191E0193E0194E0196E0197E0198E0199E0277E0280E0370E0371E0372E0373L89.101L89.159L89.200L89.229L89.301L89.329L89.40L89.45L89.810L89.899R40.0R40.1R40.3R40.4Z74.01I96R64
Original notice
Pressure Reducing Support Surfaces (CPB 0430, reviewed 2026-07-10)
aetna.com · Always check the source before changing claims.
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Related policy hubs
Aetna policiesWound CareGeriatricsCode A4640Code E0181Code E0182Code E0183Code E0184Code E0185Code E0186Code E0187Code E0188Code E0189Code E0191Code E0193Code E0194Code E0196Code E0197Code E0198Code E0199Code E0277Code E0280Code E0370Code E0371Code E0372Code E0373Code L89.101Code L89.159Code L89.200Code L89.229Code L89.301Code L89.329Code L89.40Code L89.45Code L89.810Code L89.899Code R40.0Code R40.1Code R40.3Code R40.4Code Z74.01Code I96Code R64