What is a medical necessity for a mattress? Your guide to proving the need

September 22, 2025 •

3 min read

According to one study, up to 70% of claims for Durable Medical Equipment (DME) may be initially rejected by insurers, highlighting the complexity of the process. So, what is a medical necessity for a mattress? It is the requirement of specialized bedding to effectively manage or treat a diagnosed health condition, as prescribed by a doctor.

Quick Summary

A mattress is considered a medical necessity when a physician prescribes specialized bedding to treat or prevent a specific medical condition, like managing chronic pain, preventing pressure ulcers, or aiding a patient with limited mobility. This justification allows the mattress to be classified as Durable Medical Equipment (DME) and potentially covered by health insurance, including Medicare.

Key Points

Doctor's Prescription: The process always begins with a detailed prescription from a physician outlining the medical need [4].
DME Classification: For insurance coverage, the mattress must be classified as Durable Medical Equipment (DME) [1].
Qualifying Conditions: A wide range of conditions, including immobility, respiratory issues, severe arthritis, and pressure ulcers, can qualify [2, 4, 5].
Documentation Is Key: A detailed 'Letter of Medical Necessity' from your doctor, explaining the specific medical situation, is vital [4].
Pressure Management: Preventing or treating pressure ulcers (bedsores) is one of the most common justifications for specialized mattresses [4, 5].
Insurance Process: You will likely need to use an insurance-approved DME supplier and be prepared to appeal an initial denial [4].

Establishing Medical Necessity: The Foundation

Proving that a mattress is a medical necessity is a process rooted in proper documentation and a physician's justification [4]. It requires a diagnosed, specific health condition, not just discomfort [4]. For insurance purposes, the mattress must be categorized as Durable Medical Equipment (DME), defined by Medicare as durable equipment used for a medical reason, not useful to someone without illness or injury, and appropriate for home use [1]. This classification is key for insurance coverage [4].

Qualifying Medical Conditions

Various medical conditions can necessitate a specialized mattress [2]. These often involve issues with mobility, circulation, pain, or the risk of skin breakdown [2, 4]. Common qualifying conditions include [4, 5]:

Immobility or Limited Mobility: For addressing circulation issues and preventing pressure ulcers [4].
Chronic Obstructive Pulmonary Disease (COPD): May require significant elevation of the head of the bed for easier breathing [2, 4].
Spinal Cord Injuries: Often require specific positioning and pressure management [4].
Severe Arthritis and Joint Conditions: A variable height bed can assist with safe transfers [4].
Severe Cardiac Conditions: May require upper body elevation [4].
Pressure Ulcer Prevention or Treatment: A frequent justification for pressure-reducing mattresses [4, 5].

The Physician's Role: Prescription and Documentation

Your doctor is crucial in this process, providing a prescription and thorough documentation [4]. The prescription should state the medical necessity for a specific condition [4]. Documentation must explain why an ordinary bed is inadequate [2, 4].

Types of Medical Mattresses and Their Purpose

Medical mattresses are designed for specific health issues [2, 4].

Pressure-Reducing Mattresses: Distribute weight to minimize pressure points, essential for preventing/treating pressure ulcers [2].
Alternating Pressure Mattresses: Use air cells to shift pressure points, vital for managing bedsores in immobile patients [2].
Low Air Loss Mattresses: Provide a breathable surface with airflow to manage moisture and skin temperature, preventing skin breakdown [2].
Adjustable Mattresses (Part of a Hospital Bed System): Allow head/feet elevation, important for respiratory/cardiac issues or injuries [1, 2].

The Path to Insurance Coverage

Navigating insurance requires precision [4, 5]:

Obtain a Prescription: From your physician, detailing medical necessity [4].
Request a Letter of Medical Necessity: A detailed letter from your doctor explaining your diagnosis and need [4].
Choose an Approved DME Supplier: Use a supplier approved by your insurance [4].
Submit the Claim: Often handled by the DME supplier, but stay involved [4].
Appeal Denials: Be prepared to appeal if initially denied, using your doctor's documentation [4].

Out-of-Pocket and Other Options

If insurance doesn't cover the cost, HSA or FSA funds may be usable with a physician's prescription [5]. Evaluate the cost and medical need compared to off-the-shelf options [5].

Comparison of Medical Mattresses


Mattress Type	Primary Purpose	Key Features	Best For	Typical Cost (Insurance Dependent)
Foam (Pressure-Reducing)	Redistributes pressure, prevents bedsores	Multi-layered foam, contouring, high density	Patients with moderate immobility risk	Lower
Alternating Pressure	Manages existing pressure ulcers, improves circulation	Air cells that inflate/deflate automatically	Immobile patients with high pressure risk	Medium to High
Low Air Loss	Microclimate control, prevents skin breakdown	Continuous airflow across the surface	Patients with high risk of skin moisture issues	High
Adjustable Hospital Bed System	Adjusts body positioning	Electric controls for head/foot elevation, variable height	Patients with COPD, cardiac issues, severe arthritis	Variable (highest)

Conclusion: Persistence is Key

Securing a specialized mattress based on medical necessity requires patience and meticulous record-keeping [4]. Work closely with your healthcare provider to ensure complete documentation [4]. Medical necessity is based on a demonstrable need to treat or manage a specific medical condition, not just comfort [4]. Following the correct steps increases your chances of coverage [4]. For detailed coverage information, consult your provider or the Centers for Medicare & Medicaid Services [1].

Frequently Asked Questions

No, standard retail mattresses, including memory foam mattresses, are not typically covered [5]. Insurance requires a specialized mattress explicitly designed for a medical condition that qualifies as Durable Medical Equipment (DME), such as a pressure-reducing or hospital bed mattress [2].

Proving medical necessity requires a prescription from your doctor and a detailed Letter of Medical Necessity [4]. This letter should explain your specific diagnosis, why a standard mattress is insufficient, and how the specialized mattress will treat or manage your condition [4].

A Letter of Medical Necessity is a document written by your physician that provides a detailed clinical explanation for why you require a specific medical service or piece of equipment [4]. For a mattress, it must clearly justify its use for your diagnosed condition [4].

It is highly unlikely [5]. Most health insurance providers do not cover brand-name retail mattresses, even if they have therapeutic qualities. The focus is on the function of the equipment for a diagnosed medical need, not the brand [5].

Common qualifying conditions include immobility (bedridden patients), severe respiratory issues (like COPD), spinal cord injuries, severe arthritis, and conditions that place patients at high risk for pressure ulcers (bedsores) [4, 5].

For temporary conditions, renting may be more cost-effective and covered by insurance. For permanent or long-term conditions, purchasing may be a better option [5]. Medicare often covers the rental cost for a certain period, after which ownership may be transferred [5].

No, a standard mattress for simple or general back pain is not covered [5]. Coverage under Medicare requires that the mattress is part of a hospital bed and prescribed for a more severe, documented medical condition that necessitates specialized positioning or pressure relief not feasible with a regular bed [1, 5].