`E0196` Gel pressure mattress

Gel pressure mattress

Medicare coverage: Special coverage instructions apply
Status: active (October 2026 file)

Medically Unlikely Edits (effective October 1, 2026)

Practitioner: max 0 units per day (clinical), rationale: CMS Policy
Outpatient hospital: max 0 units per day (clinical), rationale: CMS Policy
DME supplier: max 1 units per day (policy), rationale: Code Descriptor / CPT Instruction

Medicare pricing for E0196

DMEPOS fee schedule, July 2026 (DME26-C)

RR (rental), capped rental (CR): non-rural $37.71 to $42.18 in the contiguous states; $46.30 to $58.06 in AK, HI, PR and VI; rural $39.35 to $44.79

Payer policies and prior authorization for E0196

1 of 1 payer prior-auth lists that name E0196 require prior authorization or set conditions: Rocky Mountain Health Plans.

Payer	Plan	State	Prior auth	Conditions	Since	Source
Rocky Mountain Health Plans	Rocky Mountain Medicare Advantage D-SNP	CO	prior auth required		Feb 1, 2025	Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025

Payer coverage policies that name E0196

E0196 appears in 5 coverage policies from Aetna, Anthem, Capital Blue Cross, Health Care Service Corporation (BCBS IL, TX, OK, NM, MT).

Payer	Policy	Role in policy	Reviewed	Document
Aetna	Hospital Beds and Accessories (0543)	listed, no stance	Sep 23, 2026	payer document
Aetna	Pressure Reducing Support Surfaces (0430)	covered if criteria are met	Jul 10, 2026	payer document
Anthem	Pressure-Reducing Support Surfaces (CG-DME-16)	covered if criteria are met	Aug 13, 2026	payer document
Capital Blue Cross	Hospital Beds and Accessories (MP 6.001) Procedure codes	covered if criteria are met	Mar 1, 2026	payer document
Health Care Service Corporation (BCBS IL, TX, OK, NM, MT)	Hospital Beds and Related Equipment (DME101.001) HCPCS Codes A4640, E0181, E0182, E0183, E0184, E0185, E0186, E0187, E0188, E0189,	listed, no stance	Jan 1, 2026	payer document

Recent prior-auth changes

Mar 1, 2025: PA removed, Rocky Mountain Health Plans
Mar 1, 2025: PA removed, Rocky Mountain Health Plans

Medicaid fee-for-service

Prior authorization required or conditional in CO, IN, LA, MA, MS, ND, NY, VA, WV.

AZ: $284.17 (dme), effective Oct 1, 2026
CO: $31.74 (chp_plus, non-facility), effective Jul 1, 2026
FL: $197.75 (dme), effective Jul 1, 2026
IL: $295.64 (dme), effective Jan 1, 2026
IN: $349.10 (professional, Advanced Practice Nurse (85%), non-facility), effective Jan 1, 2025
KS: $250.00 (default), effective Sep 1, 2007
KY: $264.20 (dme), effective Jan 1, 2026
LA: $240.97 (dme), effective Jul 1, 2012
MD: $321.13 (dme), effective Apr 1, 2026
MS: $1.05 (comprehensive), effective Jul 1, 2026
ND: $396.90 (dme), effective Aug 1, 2026
NE: $39.69 (dme), effective Jul 1, 2026
NY: $74.74 (dme), effective Jul 1, 2026
OH: $351.69 (dme), effective Apr 1, 2006
OK: $391.00 (dme), effective Jan 1, 2026
TX: $23.76 (dmepos_tos_9_e_j_l_and_r, Home Health Dme), effective Apr 1, 2017
VA: $356.42 (dme), effective Dec 1, 2026
VT: $346.39 (outpatient_hospital_opps), effective Feb 1, 2026
WA: $416.50 (medical_equipment_supplies), effective Jul 1, 2026
WY: $0.00 (outpatient_hospital_apc, Children's Hospitals), effective Apr 1, 2026

From payers' published prior-auth lists, coverage policies and state Medicaid fee schedules, updated Oct 16, 2026. The role is what the policy's own code table or text says about the code. Not a guarantee of coverage or payment; verify with the payer. CPT® is a registered trademark of the American Medical Association.

E0196 Gel pressure mattress