Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Walkers
Policy #:MA05.037

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.

STANDARD WALKER

A standard walker (E0130, E0135, E0141, E0143) and related accessories 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, as defined by one of the following indications:
    • Prevents the individual from accomplishing the MRADL entirely
    • Places the individual at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform the MRADL
    • Prevents the individual from completing the MRADL within a reasonable time frame
  • The individual is able to safely use the walker.
  • The functional mobility deficit can be sufficiently resolved with use of a walker.

If above criteria are not met, the walker will be considered not medically necessary and, therefore, not covered.

HEAVY-DUTY WALKER

A heavy-duty walker (E0148, E0149) is considered medically necessary and, therefore, covered for individuals who meet the coverage criteria for a standard walker and who weigh more than 300 pounds.

If a heavy-duty walker (E0148 or E0149) is provided and the individual weighs 300 pounds or less, it will be considered not medically necessary, and, therefore, not covered.

HEAVY-DUTY, MULTIPLE BREAKING SYSTEM WALKER

A heavy-duty, multiple-braking-system, variable-wheel-resistance walker (E0147) is considered medically necessary, and, therefore, covered for individuals who meet coverage criteria for a standard walker and who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand.

Obesity, by itself, is not a sufficient reason for a variable wheel resistance walker. If a variable-wheel-resistance walker is provided and the additional coverage criteria are not met, it will be considered not medically necessary and, therefore, not covered.

WALKER WITH TRUNK SUPPORT

A walker with trunk support (E0140) is considered medically necessary and, therefore, covered for individuals who meet the coverage criteria for a standard walker and who have documentation in the medical record justifying the medical necessity for the special features.

If a trunk support walker (E0140) is provided without meeting the above criteria, it will be considered not medically necessary, and, therefore, not covered.

LEG EXTENSIONS

Leg extensions (E0158) are considered medically necessary and, therefore, covered only for individuals who are six feet or more in height.

WALKER WITH ENCLOSED FRAME

A walker with an enclosed frame (E0144) is considered not medically necessary, and therefore, not covered.

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.

COLUMN I/COLUMN II REIMBURSEMENT EDITS

Column II code is included in the allowance for the corresponding Column I code when provided at the same time and must not be billed separately at the time of billing the Column I code.

Column I
Column II
E0130
A4636, A4637
E0135
A4636, A4637
E0140
A4636, A4637,E0155, E0159
E0141
A4636, A4637,E0155, E0159
E0143
A4636, A4637, E0155, E0159
E0144
A4636, A4637, E0155, E0156, E0159
E0147
A4636, E0155, E0159
E0148
A4636, A4637
E0149
A4636, A4637, E0155, E0159

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, walkers 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

A walker or gait trainer is used to support an individual during ambulation. A gait trainer is a term used to describe certain devices that are used to support a patient during ambulation. Gait trainers serve the same purpose as walkers.

A wheeled walker is one with 2, 3, or 4 wheels. It may be fixed height or have an adjustable height. It may or may not include glide-type brakes (or equivalent). The wheels may be fixed or swivel.

A glide-type brake consists of a spring mechanism (or equivalent) which raises the leg post of the walker off the ground when the individual is not pushing down on the frame.

A folding wheeled walker which has a frame that completely surrounds the individual and
an attached seat in the back.

A heavy-duty walker is one which is labeled as capable of supporting beneficiaries who weigh
more than 300 pounds. It may be fixed height or adjustable height. It may be rigid or folding.

A 4-wheeled, adjustable height, folding-walker that has all of the following characteristics:
  • Capable of supporting beneficiaries who weigh greater than 350 pounds
  • Hand-operated brakes that cause the wheels to lock when the hand levers are released
  • Hand brakes that can be set so that either or both can lock both wheels
  • Pressure required to operate each hand brake is individually adjustable
  • Additional braking mechanism on the front crossbar
  • At least two wheels with brakes that can be independently set through tension adjustability to give varying resistance

References

Noridian Healthcare Solutions. Local Coverage Determination(L33791). Walkers. [Noridian Healthcare Solutions Web site] Original: 10/01/15. (Revised 01/01/2017). Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Walkers+LCD+and+PA/5c4c220b-ed8c-47fe-ad48-b30b15de5f0c. Accessed January 4, 2019.

Noridian Heathcare Solutions. Local Coverage Article(A52503). Walkers. [Noridian Healthcare Solutions Web site]. Original: 10/01/15. (Revised 01/01/2017). Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Walkers+LCD+and+PA/5c4c220b-ed8c-47fe-ad48-b30b15de5f0c. 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)



THE FOLLOWING CODES REPRESENT STANDARD WALKERS:

E0130 Walker, rigid (pickup), adjustable or fixed height

E0135 Walker, folding (pickup), adjustable or fixed height

E0141 Walker, rigid, wheeled, adjustable or fixed height

E0143 Walker, folding, wheeled, adjustable or fixed height


THE FOLLOWING CODES REPRESENT HEAVY DUTY WALKERS:

E0148 Walker, heavy-duty, without wheels, rigid or folding, any type, each

E0149 Walker, heavy-duty, wheeled, rigid or folding, any type


THE FOLLOWING CODE REPRESENTS A HEAVY DUTY, MULTIPLE BREAKING SYSTEM WALKER:

E0147 Walker, heavy-duty, multiple braking system, variable wheel resistance


THE FOLLOWING CODE REPRESENTS A WALKER WITH TRUNK SUPPORT:

E0140 Walker, with trunk support, adjustable or fixed height, any type


THE FOLLOWING CODE REPRESENTS LEG EXTENSIONS:

E0158 Leg extensions for walker, per set of 4


THE FOLLOWING CODE REPRESENTS A WALKER WITH ENCLOSED FRAME:

E0144 Walker, enclosed, 4 sided framed, rigid or folding, wheeled with posterior seat


THE FOLLOWING CODES REPRESENT REPLACEMENTS/ATTACHMENTS:

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

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

E0154 Platform attachment, walker, each

E0155 Wheel attachment, rigid pick-up walker, per pair

E0156 Seat attachment, walker

E0157 Crutch attachment, walker, each

E0159 Brake attachment for wheeled walker, replacement, each


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References




Policy History

MA05.037
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 for walkers.
04/25/2018This policy has been reviewed and reissued to communicate the Company's continuing position for walkers.
02/01/2017This policy has been reviewed and reissued to communicate the Company's continuing position for walkers.
07/06/2016This policy has been reviewed and reissued to communicate the Company's continuing position for walkers.
06/24/2015This policy has been reviewed and reissued to communicate the Company's continuing position for walkers.
01/01/2015This is a new policy.






Version Effective Date: 01/01/2015
Version Issued Date: 01/01/2015
Version Reissued Date: 02/14/2020