Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Seat Lift Mechanisms
Policy #:MA05.011a

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.

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.

Seat lift mechanisms (E0627, E0629) are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
  • The seat lift mechanism must be a part of the prescribing health care provider’s course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the individual’s condition.
  • The individual must be completely incapable of standing up from a regular armchair or any chair in their home. (The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.)
  • Once standing, the individual must have the ability to ambulate.

Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the individual, and effectively assist an individual in standing up and sitting down without other assistance. Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the individual from a seated to a standing position.

All other uses for seat lift mechanisms are considered not medically necessary and, therefore, not covered.

The reimbursement for a seat lift mechanism incorporated into a combination lift-chair mechanism (E0627) is limited to the seat lift mechanism only. The chair is not eligible for separate reimbursement and is, therefore, not covered.

A toilet seat lift mechanism (E0172) is not covered by the Company because it is an item or service not covered by Medicare. It does not meet Medicare's definition of durable medical equipment because it is not primarily medical in nature. Therefore, a toilet seat lift mechanism is not eligible for reimbursement consideration.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • The treating professional provider must have an in-person examination with the individual within the six months prior to the date of the written order prior to delivery.
  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified items are:

Code
Narrative
E0627Seat lift mechanism, electric any type
E0629Separate seat lift mechanism non-electric any type


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.

Documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

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

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, seat lift mechanisms 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 noncovered are not eligible for coverage or reimbursement by the Company.

Description

The seat lift mechanism is the portion of the patient lift chair that gently raises an individual to a standing position. It includes the metal frame on which the chair rests, the lift motor, the scissors mechanisms, and the hand control unit. The seat lift mechanism may be incorporated into a chair as a complete unit or supplied as a separate unit.
References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.4: Seat Lift. [CMS Web site]. 05/01/1989. Available at:r
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=221&ncdver=1&bc=AAAAgAAAAAAA&. Accessed June 18, 2019.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33801: Seat Lift Mechanisms. Effective 01/01/2017. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33801&ContrId=389. Accessed June 18, 2019.

Noridian Healthcare Solutions, LLC. Policy Article. A52518: Seat Lift Mechanisms. Effective 01/01/2017. Available at: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52518&ver=16&Cntrctr=389&name=&DocType=Active&DocStatus=Active&ContrVer=1&CntrctrSelected=389*1&s=9&LCntrctr=139*1&bc=AhAAAAMAAAAA&. Accessed June 18, 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)

E0627 Seat lift mechanism electric any type


E0629 Separate seat lift mechanism non-electric any type

THE FOLLOWING SEAT LIFT MECHANISM IS CONSIDERED NON-COVERED:

E0172 Seat lift mechanism placed over or on top of toilet, any type



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

MA05.11a
07/31/2019 The policy has been reviewed and reissued to communicate the Company's continuing position on Seat Lift Mechanisms



MA05.011a
04/25/2018 This policy was reviewed and reissued to communicate the Company's continuing coverage of seat lift mechanisms.
08/30/2017 This policy was reviewed and reissued to communicate the Company's continuing coverage of seat lift mechanisms.
01/01/2017This policy has been identified for the annual HCPCS code update effective 01/01/2017.
The following codes were revised: E0627 & E0629
The following code was deleted: E0628

MA05.011
04/13/2016This policy was reviewed and reissued to communicate the Company's continuing coverage of seat lift mechanisms.
04/15/2015This policy was reviewed and reissued to communicate the Company's continuing coverage of seat lift mechanisms.
01/01/2015This is a new policy.






Version Effective Date: 01/01/2017
Version Issued Date: 12/30/2016
Version Reissued Date: 07/31/2019