Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Seat Lift Mechanisms

Policy #:05.00.43f

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


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. 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.

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 Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

MEDICALLY NECESSARY

SEAT LIFT MECHANISMS
Seat lift mechanisms are considered medically necessary and, therefore, covered when an individual or the individual's caregiver is able to control the device, and all of the following criteria are met:
  • The individual has severe arthritis of the hip or knee or has a severe neuromuscular disease.
  • The individual is completely incapable of standing up from a regular armchair or from any other chair in the home.
  • The individual can ambulate.
  • The individual has tried and failed the appropriate therapeutic modalities (eg, medication, physical therapy) that would enable him or her to transfer from a chair to a standing position.
  • The seat lift mechanism is supplied by a DME provider.
  • The seat lift mechanism must be a part of the professional provider's course of treatment and prescribed to improve the individual's condition or to arrest or retard deterioration in the individual’s condition.

Coverage of seat lift mechanisms is limited to those types that operate smoothly and safely. The type of lift that operates by spring release mechanisms, which involves a sudden, catapult-like motion to jolt the individual from a seated to a standing position, is considered not medically necessary and, therefore, not covered because the safety and effectiveness for this type of seat lift mechanism have not been established.

COMMODE CHAIR WITH INTEGRATED SEAT LIFT MECHANISM
A commode chair with an integrated seat lift mechanism is considered medically necessary and, therefore, covered when an individual meets both of the following criteria:
  • The individual meets all of the above criteria for a seat lift mechanism.
  • The individual is incapable of utilizing regular toilet facilities for one of the following reasons:
    • The individual is confined to a single room.
    • The individual is confined to one level of the home, and there is no toilet on that level.
    • The individual is confined to the home, and there are no toilet facilities in the home.

WHEELCHAIR ACCESSORY SEAT LIFT MECHANISM
A wheelchair accessory seat lift mechanism (HCPCS code E0985) is considered medically necessary and, therefore, covered when the following criteria are met:
  • The individual meets the requirements for a wheelchair (refer to Cross References for links to applicable medical policies).
  • The individual meets all of the above criteria for a seat lift mechanism, with the exception of the ability to ambulate.

CODING GUIDELINES

INTEGRATED CHAIR WITH SEAT LIFT
When providing a seat lift mechanism that is incorporated into a chair as a complete unit at the time of purchase, the DME provider must bill for the items using the established HCPCS code E0627. The DME provider may bill for the seat lift mechanism using HCPCS code E0627 and the appropriate code for the chair.

PATIENT-OWNED FURNITURE WITH SEAT LIFT
If the seat lift mechanism, electric or non-electric, is supplied as a stand-alone unit to be incorporated into a chair that the individual already owns, the DME provider must bill using the appropriate code for the seat lift mechanism for use with patient-owned furniture, HCPCS code E0629.

COMMODE WITH INTEGRATED SEAT LIFT MECHANISM
A commode with an integrated seat lift mechanism (HCPCS E0170, E0171) is a free-standing device that has a commode pan and an integrated seat that can be raised with or without a forward tilt while the person is seated. An integrated device is one that is sold as a unit by the manufacturer and in which the lift and commode cannot be separated without the use of tools.

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual, for whom certain specified items are 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 is 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:
E0627 SEAT LIFT MECHANISM ELECTRIC ANY TYPE
E0629 SEPARATE 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, seat lift mechanisms are covered under the medical benefits of the Company’s products when the medical necessity criteria listed in the medical policy are met.

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


Company Benefit Contracts.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD).L33736: Commodes. Effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Commodes Accessed March 8, 2018.

Noridian Healthcare Solutions, LLC. Policy Article A52461. Commodes. Effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Commodes Accessed March 8, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33801: Seat Lift Mechanisms. Effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Seat+Lift+Mechanisms+LCD/9db611fb-cfd9-4162-8ec6-bb4afb237be7. Accessed March 8, 2018.

Noridian Healthcare Solutions, LLC. Policy Article. A52518: Seat Lift Mechanisms. Effective 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Seat+Lift+Mechanisms+LCD/9db611fb-cfd9-4162-8ec6-bb4afb237be7. Accessed March 8, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33792. Wheelchair Options and Accessories. Effective 01/01/2018. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Wheelchair+Options+Accessories+LCD/af84d4d7-2912-453f-8e94-ab45c5c433ec. Accessed March 8, 2018.

Noridian Healthcare Solutions, LLC. Policy Article. A52504. Wheelchair Options and Accessories. Effective 01/01/2018. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Wheelchair+Options+Accessories+LCD/af84d4d7-2912-453f-8e94-ab45c5c433ec. Accessed March 8, 2018.





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


E0170 Commode chair with integrated seat lift mechanism, electric, any type

E0171 Commode chair with integrated seat lift mechanism, non-electric, any type

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

E0627 Seat lift mechanism electric any type

E0629 Separate seat lift mechanism, non-electric any type

E0985 Wheelchair accessory, seat lift mechanism



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

05.00.43f
04/25/2018This policy was reviewed and reissued to communicate the Company's continuing coverage of seat lift mechanisms.


Effective 10/05/2017 this policy has been updated to the new policy template format.
Version Effective Date: 01/01/2017
Version Issued Date: 12/30/2016
Version Reissued Date: 04/25/2018

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.