New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 59 - MEDICAL SUPPLIER MANUAL
Subchapter 1 - MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT
Section 10:59-1.14 - Pressure reduction systems

Universal Citation: NJ Admin Code 10:59-1.14

Current through Register Vol. 56, No. 18, September 16, 2024

(a) Pressure reduction systems include:

1. Air fluidized bed systems which employ the circulation of filtered air through silicone-coated ceramic beads creating the characteristics of fluid;

2. Powered low air loss bed systems which incorporate the use of an air-bladder system consisting of a series of interconnected adjustable air sacs designed to allow air escape to reduce support surface pressure. Air to the sacs is supplied by a separate power supply unit; and

3. Low end products which include any powered or non-powered overlay or mattress.

(b) Policies for providing and authorizing DME as described in 10:59-1.5 and 1.6 apply.

(c) Reimbursement for low end products is included in the NF's per diem, and therefore shall not be covered.

(d) Periods of Prior Authorization (PA) for air-fluidized and powered low air loss bed systems shall be limited to 30 days.

(e) Requests for PA for air fluidized and low air loss bed systems shall include the following:

1. A medical history relating to the wound which includes previous therapy and pressure relief systems utilized and found unsuccessful;

2. Physician progress notes indicating medical necessity, plan of treatment, and evaluation of response to treatment specific to the care of the wound;

3. A wound care flow sheet documenting weekly the site, size, depth and stage of the wound, noting also the presence and description of drainage or odor;

4. Laboratory values include a complete blood count and blood chemistries initially and on request thereafter;

5. A nutritional assessment by a registered dietitian initially and on request thereafter; and

6. Photographs of the site, upon permission of the beneficiary/family, after full due consideration is afforded to the beneficiary's right to privacy, dignity and confidentiality.

(f) Coverage for air fluidized and low air loss bed systems shall be limited to the following conditions:

1. The beneficiary has two stage III (full-thickness tissue loss) pressure sores or a stage IV (deep tissue destruction) pressure sore which involves two of the following sites: hips, buttocks, or sacrum; and

2. The beneficiary is bedridden or chairbound as a result of severely limited mobility; and

3. The beneficiary is receiving maximal medical/nursing care, previously instituted conservative treatment has been unsuccessful and all other alternative equipment has been considered and ruled out.

4. If the beneficiary has coexisting risk factors (such as vascular irregularities, nutritional depletion, diabetes or immune suppression), they must present post-operatively with a posterior or lateral flap or graft site requiring short-term therapy until the operative site is viable.

(g) Coverage for conditions other than those described in (e) above may be considered on an individual basis by the MDO.

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