Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Canes and Crutches
Policy #:MA05.052b

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.

MEDICALLY NECESSARY

Canes (E0100, E0105) and crutches (E0110--E0116) are considered medically necessary and, therefore, covered when ALL of the following criteria are met:
  • The individual has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADL) in the home; AND,
  • The individual is able to safely use the cane or crutch; AND,
  • The individual's functional mobility deficit can be sufficiently resolved by the use of a cane or crutch.

NOT MEDICALLY NECESSARY

An underarm, articulating, spring-assisted crutch (E0117) is considered not medically necessary and, therefore, not covered.

All other uses for canes and crutches are considered not medically necessary and, therefore, not covered.

NOT COVERED

A crutch substitute, lower leg platform, with or without wheels (E0118), is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

A white cane, typically used for a blind individual, is not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

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

The mobility-related activities of daily living (MRADLs) include toileting, feeding, dressing, grooming, and bathing, performed in the home.

A mobility limitation is any of the following:
  • A limitation that prevents the individual from accomplishing the MRADL
  • A limitation that places the individual at a risk of morbidity or mortality secondary to their attempts to perform a MRADL
  • A limitation that prevents the individual from completing the MRADL within a reasonable time frame

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, canes and crutches 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 covered are not eligible for coverage or reimbursement by the Company.

Description

Canes and crutches are types of assisted walking devices.

Refer to the Billing and Coding Requirements section of this policy for a description of canes and crutches and the applicable Healthcare Common Procedural Coding System (HCPCS) code for each item.
References

Noridian Healthcare Solutions. Local Coverage Article (A52459). Canes and Crutches. [Noridian Health-care Solutions] Original: 10/01/2015. (Revised 01/01/2017). Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Canes+and+Crutches/01569c01-e4f2-4e7a-b480-ad860998adc3. Accessed January 4, 2019.

Noridian Healthcare Solutions. Local Coverage Determination(L33733). Canes and Crutches Original:10/01/2015. (Revised 01/01/2017). Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Canes+and+Crutches/01569c01-e4f2-4e7a-b480-ad860998adc3. Accessed January 4, 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)



MEDICALLY NECESSARY

Canes

E0100 Cane, includes canes of all materials, adjustable or fixed, with tip

E0105 Cane, quad or 3-prong, includes canes of all materials, adjustable or fixed, with tips

Crutches

E0110 Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips

E0111 Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrips

E0112 Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips, and handgrips

E0113 Crutch, underarm, wood, adjustable or fixed, each, with pad, tip, and handgrip

E0114 Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips, and handgrips

E0116 Crutch, underarm, other than wood, adjustable or fixed, with pad, tip, handgrip, with or without shock absorber, each

Replacements/Attachments

A4635 Underarm pad, crutch, replacement, each

A4636 Replacement, handgrip, cane, crutch, or walker, each

A4637 Replacement, tip, cane, crutch, walker, each

E0153 Platform attachment, forearm crutch, each


NOT MEDICALLY NECESSARY

E0117 Crutch, underarm, articulating, spring assisted, each


NOT COVERED

E0118 Crutch substitute, lower leg platform, with or without wheels, each

THE FOLLOWING CODE IS USED TO REPRESENT A WHITE CANE FOR A PERSON WHO IS BLIND:

E1399 Durable medical equipment, miscellaneous


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References




Policy History

MA05.052b
02/12/2020This policy has been reissued in accordance with the Company's annual review process.
02/13/2019This policy has been reviewed and reissued to communicate the Company’s continuing position on Canes and Crutches.
03/28/2018The policy has been reviewed and reissued to communicate the Company’s continuing position on Canes and Crutches.
03/10/2017In accordance with Medicare, the Company’s coverage position has changed from Medically Necessary to Not Covered for the following item represented by:
  • E0118 Crutch substitute, lower leg platform, with or without wheels, each

MA05.052a
02/03/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on canes and crutches.
03/18/2015The following HCPCS code has been added to this policy to represent a white cane:
  • E1399 Durable medical equipment, miscellaneous

The following HCPCS code has been removed from this policy:
  • A9270 Noncovered item or service

MA05.052
01/01/2015This is a new policy.






Version Effective Date: 03/10/2017
Version Issued Date: 03/10/2017
Version Reissued Date: 02/14/2020