Who pays, and how

How this equipment is actually paid for

Most people arrive here having been told a therapy surface is needed and having assumed, reasonably, that insurance handles it. Sometimes it does. For this particular product, it does not, and the useful thing we can do is explain the system accurately enough that you can work out where your own situation sits.

So this section is written as an explanation rather than a sales funnel. It sets out what Medicare’s support-surface categories are and what a clinician must document for each, what Medicaid and waiver programs do differently, how commercial plans treat these items, and what an HSA or FSA can and cannot do. Where the honest answer is that a different surface through a different supplier is what your benefit will pay for, the pages say so.

One thing is true across all four and is easier to read once than to discover four times: we do not bill Medicare, Medicaid or commercial insurers, and we do not submit claims on anyone’s behalf. A Dolphin® FIS® surface is bought or rented privately.

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Funding guides

Medicare

How Medicare covers pressure-reducing support surfaces: the Group 1, 2 and 3 codes, the criteria a clinician must document, and where Dolphin FIS sits.

Medicaid & Waivers

How Medicaid covers hospital beds and pressure-reducing mattresses: state variation, managed-care prior authorization, and what to ask your case manager.

HSA & FSA

How an HSA or FSA can apply to a therapy mattress: the dual-purpose item problem, what a Letter of Medical Necessity does, and who actually decides.

Private Insurance

Are alternating pressure and low air loss mattresses covered by insurance? How commercial medical policy, prior authorization and appeals work.

We bill: Nobody. Private payment, facility PO, or VA contracting
FIS coding: No HCPCS code of its own; not an air-fluidized bed
Covered surfaces: Group 2 and Group 3 items, through an enrolled DME supplier
HSA / FSA: A mechanism, not a promise — the administrator decides

Working out who pays, in order

1
Ask what the clinical need actually is
A surface is prescribed for a reason: an ulcer at a stage, a flap or graft, an inability to be turned. That reason decides which categories are even in play.
2
Check the covered categories first
If a Group 2 surface would meet the need and the criteria are met, it is coded and billable through an enrolled DME supplier. That is the cheapest route and it is not us.
3
Establish what your plan requires
Prior authorization, a Standard Written Order, documentation of a treatment program, monthly recertification for Group 3. The requirement is the work, not the phone call.
4
Then price the private route
If the surface the care team wants is a Dolphin FIS, it is a private rental or purchase. The pricing page carries the bands, and renting keeps it a monthly cost rather than a capital one.
5
Ask your administrator about an HSA or FSA
A clinician’s Letter of Medical Necessity is the mechanism that puts a dual-purpose item in front of an administrator. They decide; we can supply an itemized receipt.

The four guides, and what each one is for

The Medicare guide is the longest and the most used. It explains the three groups of pressure-reducing support surfaces, names the codes as CMS defines them, sets out what a clinician has to document for a Group 2 or a Group 3 surface, and answers the question the whole site turns on: whether Medicare covers a Dolphin FIS mattress.

The Medicaid guide covers state programs, managed care and home-and-community-based waivers, which vary so much by state that the useful content is about how to find your own answer rather than a claim about all fifty. The private insurance guide covers commercial plans, prior authorization and appeals, including how an alternating pressure mattress is usually treated. And the HSA and FSA guide explains the Letter of Medical Necessity mechanism and its limits.

Medicare — the three groups, the codes, the criteria, and where FIS sits
Medicaid and waivers — state variation, managed care, and where to ask
Private insurance — commercial plans, prior authorization and appeals
HSA and FSA — dual-purpose items, the LMN mechanism, and who decides

The three groups, in one paragraph each

Medicare sorts pressure-reducing support surfaces into three groups. Group 1 is the non-powered tier: foam, gel, water and non-powered air overlays and mattresses. It is where a comprehensive treatment program usually starts, and being on an appropriate Group 1 surface is part of what has to be documented before a Group 2 surface is covered for stage 2 ulcers.

Group 2 is the powered tier, plus advanced non-powered surfaces. CMS defines E0277 as a powered pressure reducing mattress — alternating pressure, low air loss, or powered flotation without low air loss — with an air pump or blower and an inflated cell height of five inches or greater, placed directly on a hospital bed frame. E0372 is the powered overlay version at three and a half inches or greater. E0371 is an advanced non-powered overlay at three inches or greater, and E0373 an advanced non-powered mattress at five inches or greater. These are the surfaces most people mean when they say "low air loss mattress" or "alternating pressure mattress", and they are coded and billable.

Group 3 is a single code, E0194, the air-fluidized bed: warm filtered air circulated through silicone-coated ceramic beads to create fluid characteristics, with heavy-duty and bariatric versions under the same code. Its coverage criteria are the strictest of the three.

What that means for you, in practice

If the clinical need can be met by a Group 2 surface and the criteria are met, pursue that. It is coded, an enrolled DME supplier can bill it, and it will cost the household far less than a private rental. Your clinician or discharge planner can start it; the Medicare guide sets out the criteria so you can see whether you are close.

If the care team specifically wants fluid immersion simulation, there is no benefit to apply for and no authorization to chase. It is rented or bought privately, on a facility purchase order, or through a VA health network’s contracting process. That is a hard sentence to read when you were hoping otherwise, and it is better read now than at a delivery.

And if you have been told by anyone that a Dolphin FIS is Medicare-approved, Medicare-eligible or billable under E0194, that is wrong. At least one major commercial payer classifies fluid immersion simulation as experimental, investigational or unproven, and considers it institutional equipment inappropriate for home use. We would rather tell you that than take an order you expected to be reimbursed.

The questions worth asking, and who to ask them of

Different questions belong to different people, and the commonest waste of a week is asking the right question of the wrong one. Coverage criteria and documentation belong to the treating practitioner, the wound-care nurse and the discharge planner. Whether a specific item is billable belongs to an enrolled DME supplier. Whether an HSA or FSA claim will be honoured belongs to your plan administrator. Prices and availability belong to us.

The single most useful question for a family to put to a care team is this one: is a covered Group 2 surface appropriate here first? It is the question that decides everything downstream, and it is one that only a clinician can answer.

To the care team: is a covered Group 2 surface appropriate here first?
To the care team: what exactly will the documentation show, and does it meet the criteria?
To a DME supplier: is this item billable, and what do you need from the practitioner?
To your plan administrator: what does this plan require for a dual-purpose item with an LMN?
To us: what does it cost to rent or to buy, and will it fit the bed we have?

Before you call a payer

The patient’s diagnosis and, for an ulcer, its stage and location
What the treatment program has included so far, and for how long
Which surface the patient is currently on, and since when
Whether there has been a flap or graft, and the date of it
The date of any discharge in the past 30 days
The exact item and, if it has one, the HCPCS code the supplier will bill
Your plan’s prior authorization requirement, if any
The name and number of the practitioner who will provide the order and documentation

Questions people ask us

Do you bill insurance at all?

No. Not Medicare, not Medicaid, not commercial plans. Surfaces are bought or rented privately, on a facility purchase order, or through a VA health network’s contracting process.

Can I use my HSA or FSA?

Often, with a Letter of Medical Necessity from your clinician, because a mattress is a dual-purpose item and is not eligible on its own. Your plan administrator decides, applying IRS rules to your claim. We can provide an itemized receipt suited to substantiation; we cannot write or supply the letter.

What is the difference between Group 2 and Group 3?

Group 2 is the powered tier — alternating pressure, low air loss and powered flotation surfaces, plus advanced non-powered ones. Group 3 is a single code, E0194, for the air-fluidized bed, which circulates warm filtered air through silicone-coated ceramic beads. The criteria for Group 3 are considerably stricter.

Is there any route where insurance pays for what you supply?

Not through a claim we submit. Some households are reimbursed through an HSA or FSA at their administrator’s discretion, and facilities and VA networks buy through their own budgets and contracting. If a covered surface would meet the clinical need, pursuing that with an enrolled DME supplier is the better route and we will say so.

Work out the funding before you order

Read the guide that matches your situation, take the questions to your care team, and come back to us for what a rental or a purchase actually costs. We would rather you ordered with your eyes open than at all.

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