Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Wheelchair Cushions and Seating
Policy #:MA05.023a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

GENERAL SEAT AND BACK CUSHIONS

A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611, E2612) are considered medically necessary and, therefore, covered, for an individual who has a manual wheelchair or a power wheelchair with a sling/solid seat/back that meets the medically necessary coverage criteria for the wheelchair.

POWER-OPERATED VEHICLE (POV) OR POWER WHEELCHAIR

A POV or power wheelchair with Captain’s Chair is considered medically necessary and, therefore, covered, for an individual who needs appropriate support but does not have special skin protection or positioning needs.

A general use cushion is considered medically necessary and, therefore, covered for an individual who has a power wheelchair with a sling/solid seat/back, instead of a Captain's Chair, when either of the following criteria is met:
  • The cushion is provided with a medically necessary power wheelchair base that is not available in a Captain’s Chair model.
  • A skin protection and/or positioning seat or back cushion is provided that meets the medical necessity criteria.

SKIN PROTECTION SEAT CUSHION

A skin protection seat cushion (E2603, E2604, E2622, E2623) is considered medically necessary and, therefore, covered when an individual meets both of the following criteria:
  • The individual has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the individual meets the medical necessity coverage criteria for the wheelchair.
  • The individual has either of the following:
    • Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface
    • Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses:
      • spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post-polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, muscular dystrophy, hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease, or transverse myelitis.

POSITIONING SEAT OR BACK CUSHIONS

A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) are considered medically necessary, and, therefore, covered, for an individual who meets both of the following criteria:
  • The individual has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the individual meets the medical necessity coverage criteria for the wheelchair.
    • The individual has any significant postural asymmetries that are due to one of the following diagnoses: Spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post-polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, muscular dystrophy, hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, athetoid cerebral palsy, monoplegia of the lower limb, due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease, above-knee leg amputation, osteogenesis imperfecta, or transverse myelitis.

HEADREST

A headrest (E0955) is considered medically necessary and, therefore, covered, when the individual has a medically necessary, manual tilt-in-space, manual semi- or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.

COMBINATION SKIN PROTECTION AND POSITIONING SEAT CUSHION

A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is considered medically necessary, and, therefore, covered, for an individual who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

CUSTOM-FABRICATED SEAT CUSHION

A custom-fabricated seat cushion (E2609) is considered medically necessary, and, therefore, covered, when both of the following criteria are met.
  • The individual meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion.
  • There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), that clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs.

A custom-fabricated back cushion (E2617) is considered medically necessary and, therefore, covered, when both of the following criteria are met:
  • The individual meets all of the criteria for a prefabricated positioning back cushion; and
  • There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the individual’s seating and positioning needs.

NOT MEDICALLY NECESSARY CUSHION AND SEATING ITEMS

If the individual does not have a medically necessary wheelchair, then the cushion(s) are considered not medically necessary and, therefore, not covered.

A general use seat cushion and/or a general use wheelchair back cushion that does not meet the above criteria is considered not medically necessary and therefore, not covered.

If the individual has a POV or a power wheelchair with a captain's chair seat, a separate seat and/or back cushion is considered not medically necessary and, therefore, not covered.

If the individual has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory is considered not medically necessary, and, therefore, not covered.

If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion does not meet the above criteria, the item is considered not medically necessary and, therefore, not covered.

A positioning back cushion that does not meet the above criteria is considered not medically necessary and, therefore, not covered.

If a positioning accessory is provided and the criteria are not met, the item is considered not medically necessary and, therefore, not covered.

If a custom-fabricated seat or back cushion is provided for an individual who does not meet the criteria, the item is considered not medically necessary and, therefore, not covered.

A seat or back cushion that is provided for use with a transport chair (E1037, E1038) is considered not medically necessary and, therefore, not covered.

A powered seat cushion (E2610) is considered not medically necessary and, therefore, not covered.

A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom-fabricated seat or back cushion that does not meet the above criteria is considered not medically necessary and, therefore, not covered.

A wheelchair accessory, seat or back cushion that does not meet the definition of a specific wheelchair accessory, seat or back cushion (K0669) is considered not medically necessary and, therefore, not covered

ADDITIONAL REIMBURSEMENT CONSIDERATIONS

A loaner wheelchair seat and/or back cushion may be required when a wheelchair seat and/or back cushion needs repair and must be removed from the individual for more than one day. In this case, the following guidelines apply:
  • When repairs are required during a rental period, the loaner wheelchair seat and/or back cushion is not eligible for reimbursement. The Company-contracted durable medical equipment (DME) provider who supplied the rental wheelchair seat and/or back cushion must supply the loaner wheelchair seat and/or back cushion.
  • When a purchased wheelchair seat and/or back cushion requires repair, the loaner wheelchair seat and/or back cushion is not eligible for reimbursement. A one-month rental of a wheelchair seat and/or back cushion is considered medically necessary and, therefore, covered.
  • A loaner wheelchair seat and/or back cushion should be billed using the specific code for this item.

A solid base is included in the allowance for a wheelchair seat/back cushion; therefore, a solid insert (E0992) that is used with a seat/back cushion is not eligible for separate reimbursement.

Mounting hardware for a seat/back cushion is not eligible for separate reimbursement.

If a wheelchair seat/back cushion is billed for use with a rollabout chair, it will be denied as not separately reimbursable.

REPAIR AND REPLACEMENT

For more information on criteria for the repair and replacement of wheelchair cushions and seating, refer to the policy addressing the repair and replacement of durable medical equipment (DME).

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, wheelchair seating and cushions are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not medically necessary are not eligible for coverage or reimbursement by the Company.

Description

Wheelchair cushions and seating items, which include wheelchair backs and positioning components, are a type of durable medical equipment (DME) used with mobility-assistive equipment (eg, manual wheelchairs and power wheelchairs). Sling-style seats and backs made from upholstery are the standard wheelchair support surfaces. However, individuals may require specialized wheelchair cushions and/or backs in addition to, or in place of, sling upholstery. These specialized wheelchair cushions and backs can be used to provide postural support, to correct or compensate for postural deformities, to reduce pressure on bony prominences, and to allow pressure to be distributed evenly.

Specialized wheelchair cushions are generally prefabricated and may be constructed from a variety of flexible materials (eg, foam, gel, air). These materials relieve pressure caused by prolonged seated positioning and can be supported by more rigid materials, such as wood and plastic, which provide stability. Each material has unique advantages and disadvantages. Foam comes in varying thickness and densities and may have memory qualities that enable it to conform to the individual user. Foam cushions are stable and provide minimal to moderate pressure relief with little maintenance. Fluid-filled, or gel, cushions consist of fluid-filled pouches laid over firm foam. They offer moderate stability and pressure relief; however, they may become too hard or too soft when exposed to extreme temperatures and require moderate maintenance. Air cushions are constructed of multiple bladders that are inflated with an individualized amount of air for maximum pressure relief. Air cushions provide good pressure relief but less stability and may require more maintenance from the user and/or caregiver.

Generally, specialized wheelchair backs are prefabricated and constructed with a rigid material such as metal, plastic, or wood that is covered with a pressure-relieving material, usually foam or gel. They may be flat or contoured and can provide points of attachment for other positioning components such as headrests and lateral supports.

A positioning back cushion is a prefabricated cushion that has the following characteristics:
  • For codes, there are at least 25 mm of posterior contour in the pre-loaded state. A posterior contour is a backward curve measured from a vertical line in the midline of the cushion; and
  • For posterior-lateral cushions and for planar cushions with lateral supports, there are at least 75 mm of lateral contour in the pre-loaded state.

A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion; for posterior pelvic cushions, there is mounting hardware that is adjustable for vertical position, depth, and angle. A lateral contour has a removable vapor-permeable or waterproof cover, or it has a waterproof surface, a permanent label indicating the model and the manufacturer; and a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months. Included in this definition of a lateral contour are cushions that have a planar surface but have positioning features within the cushion that are made of a firmer material than the surface material.

A positioning back cushion may have materials or components that may be added or removed to help address orthopedic deformities or postural asymmetries.

A custom-fabricated seat cushion and a custom-fabricated back cushion are cushions that are individually made for a specific individual starting with basic materials including liquid foam or a block of foam and sheets of fabric- or liquid-coating material.

The cushion must be fabricated using molded-to-the individual-model technique, direct molded-to-the individual technique, CAD-CAM technology, or detailed measurements of the individual used to create a configured cushion.

The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor permeable or a waterproof cover or it must have a waterproof surface. A custom-fabricated cushion may include certain prefabricated components (e.g., gel or multi-cellular air inserts).

A powered wheelchair seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure cushion.

A headrest extension is a sling support for the head.
References

Noridian Healthcare Solutions. Local Coverage Article(A52505). Wheelchair Seating. [Noridian Web site]. Original 10/01/2015. (Revised:10/01/2018). Available at: https:// www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleld=52505&ver=19&MCDld=26&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCD%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=34%7c48%7c53%7c58&KeyWord=forms&KeyWordLookUp=Doc&KeyWodSearchType=Exact&kq=true&bc=IAAAACAAAAAA&. Accessed April 26, 2019.

Noridian Healthcare Solutions. Local Coverage Determination (L33312). Wheelchair Seating. [Noridian Web site]. Original 10/01/15. (Revised: 10/01/2018). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33312&ContrId=389. Accessed April 26, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)



THE FOLLOWING CODES ARE MEDICALLY NECESSARY WITH CRITERIA:

E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each

E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each

E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each

E0957 Wheelchair accessory, medial thigh support, any ype, including fixed mounting hardware, each

E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware

E0966 Manual wheelchair accessory, headrest extension, each

E0992 Manual wheelchair accessory, solid seat insert

E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware

E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware

E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware

E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware

E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware

E2601 General use wheelchair seat cushion, width less than 22 in, any depth

E2602 General use wheelchair seat cushion, width 22 in or greater, any depth

E2603 Skin protection wheelchair seat cushion, width less than 22 in, any depth

E2604 Skin protection wheelchair seat cushion, width 22 in or greater, any depth

E2605 Positioning wheelchair seat cushion, width less than 22 in, any depth

E2606 Positioning wheelchair seat cushion, width 22 in or greater, any depth

E2607 Skin protection and positioning wheelchair seat cushion, width less than 22 in, any depth

E2608 Skin protection and positioning wheelchair seat cushion, width 22 in or greater, any depth

E2609 Custom fabricated wheelchair seat cushion, any size

E2611 General use wheelchair back cushion, width less than 22 in, any height, including any type mounting hardware

E2612 General use wheelchair back cushion, width 22 in or greater, any height, including any type mounting hardware

E2613 Positioning wheelchair back cushion, posterior, width less than 22 in, any height, including any type mounting hardware

E2614 Positioning wheelchair back cushion, posterior, width 22 in or greater, any height, including any type mounting hardware

E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 in, any height, including any type mounting hardware

E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware

E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting hardware

E2619 Replacement cover for wheelchair seat cushion or back cushion, each

E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in, any height, including any type mounting hardware

E2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware

E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth

E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth

E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth

E2625 Skin protection and position wheelchair seat cushion, adjustable, width 22 inches or greater, any depth

K0108 Wheelchair component or accessory, not otherwise specified

THE FOLLOWING CODE IS CONSIDERED NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT:

A9900 Miscellaneous DME supply, accessory, and/or service component of another HCPCS code

THE FOLLOWING CODES ARE CONSIDERED NOT MEDICALLY NECESSARY:

E2610 Wheelchair seat cushion, powered

K0669 Wheelchair accessory, wheelchair seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.023a
06/05/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Wheelchair Cushions and Seating



MA05.023a
09/26/2018This policy has been reissued in accordance with the Company's annual review process.
01/01/2018This policy has been identified for the HCPCS code update, effective 01/01/2018.

The following HCPCS codes have been added to this policy:
  • E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
  • E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

MA05.023
06/21/2017This policy has been reissued in accordance with the Company's annual review process.
08/03/2016This policy has been reviewed and reissued to communicate the Company's continuing coverage for wheelchair cushions and seating.
04/29/2015This policy has been reviewed and reissued to communicate the Company's continuing coverage for wheelchair cushions and seating.
01/01/2015This is a new policy.






Version Effective Date: 12/29/2017
Version Issued Date: 12/29/2017
Version Reissued Date: 06/05/2019