Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Wheelchair Cushions and Seating

Policy #:05.00.55i

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.

Wheelchair cushions and seating items, including backs and positioning components, are considered medically necessary and, therefore, covered when the individual has a wheelchair that meets Company coverage criteria, and the seat/back cushion or positioning component is considered medically necessary. Also, for specific cushions and seating items, additional medical necessity criteria apply. These items are included in the following sections.

MEDICALLY NECESSARY CUSHIONS AND SEATING ITEMS

GENERAL-USE SEAT CUSHIONS AND BACK CUSHIONS
General-use seat cushions (HCPCS codes E2601 and E2602) and back cushions (HCPCS codes E2611 and E2612) are considered medically necessary and, therefore, covered when an individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair with a sling or solid seat or back (refer to the Cross References section in this policy for more information on policies addressing coverage of manual wheelchairs and power wheelchairs.

NONADJUSTABLE SKIN-PROTECTION SEAT CUSHIONS AND ADJUSTABLE SKIN-PROTECTION SEAT CUSHIONS
Nonadjustable, skin-protection seat cushions (HCPCS codes E2603 and E2604) or adjustable, skin-protection seat cushions (HCPCS codes E2622 and E2623) are considered medically necessary and, therefore, covered when an individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair with a sling or solid seat, in addition to either of the following medical necessity criteria:
  • The individual has a pressure ulcer or a history of a pressure ulcer that was/is located on an area of their body that makes contact with the seating surface.
  • The individual experiences absent or impaired sensation in the area where their body makes contact with the seating surface or is unable to carry out a functional weight shift due to one of the following conditions:
    • Alzheimer’s disease
    • Anterior horn cell diseases including amyotrophic lateral sclerosis
    • Arthrogryposis
    • Cerebral palsy
    • Childhood cerebral degeneration
    • Hemiplegia
    • Huntington’s chorea
    • Idiopathic torsion dystonia
    • Multiple sclerosis
    • Muscular dystrophy
    • Demyelinating diseases (e.g., progressive multifocal leukoencephalopathy, leukodystrophies
    • Osteogenesis imperfecta
    • Other spinal cord diseases
    • Parkinson’s disease
    • Post-polio paralysis
    • Spina bifida
    • Spinal cord injury resulting in quadriplegia or paraplegia
    • Spinocerebellar disease
    • Transverse myelitis
    • Traumatic brain injury resulting in quadriplegia

POSITIONING SEAT CUSHIONS, BACK CUSHIONS, AND ACCESSORIES
Positioning seat cushions (HCPCS codes E2605 and E2606), positioning back cushions (HCPCS codes E2613, E2614, E2615, E2616, E2620, E2621), and positioning accessories (HCPCS codes E0955, E0956, E0957, E0960) are considered medically necessary and, therefore, covered when the individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair that has a sling or solid seat or back, and the individual has significant postural asymmetries due to one of the following conditions:
  • Above-knee leg amputation
  • Alzheimer’s disease
  • Anterior horn cell diseases including amyotrophic lateral sclerosis
  • Cerebral palsy
  • Childhood cerebral degeneration
  • Hemiplegia
  • Huntington’s chorea
  • Idiopathic torsion dystonia
  • Monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology
  • Multiple sclerosis
  • Muscular dystrophy
  • Osteogenesis imperfecta
  • Demyelinating disease
  • Parkinson’s disease
  • Post-polio paralysis
  • Spina bifida
  • Spinal cord disease
  • Spinal cord injury resulting in quadriplegia or paraplegia
  • Spinocerebellar disease
  • Transverse myelitis
  • Traumatic brain injury resulting in quadriplegia

NONADJUSTABLE COMBINATION SKIN-PROTECTION AND POSITIONING SEAT CUSHIONS AND ADJUSTABLE COMBINATION SKIN-PROTECTION AND POSITIONING SEAT CUSHIONS
Nonadjustable, combination skin-protection and positioning seat cushions (HCPCS codes E2607 and E2608) or adjustable, combination skin-protection and positioning seat cushions (HCPCS codes E2624 and E2625) are considered medically necessary and, therefore, covered when the individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair in addition to all of the criteria for both a skin-protection seat cushion and a positioning seat/back cushion.

CUSTOM-FABRICATED SEAT CUSHIONS
Custom-fabricated seat cushions (HCPCS code E2609) are considered medically necessary and, therefore, covered when the individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair in addition to all of the following criteria:
  • The individual meets all of the medical necessity 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.

CUSTOM-FABRICATED BACK CUSHIONS
A custom-fabricated back cushion (HCPCS code E2617) is considered medically necessary and, therefore, covered when the individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair in addition to all of the following criteria:
  • The individual meets all of the criteria for a prefabricated positioning back cushion.
  • There is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT that clearly explains why a prefabricated seating system is not sufficient to meet the individual's seating and positioning needs.

HEADRESTS
A headrest (HCPCS code E0955) and headrest extension (HCPCS code E0966) are considered medically necessary and, therefore, covered when an individual has a covered manual tilt-in-space, manual semi/fully reclining back, or power tilt and/or recline power seating system.

NOT MEDICALLY NECESSARY CUSHION AND SEATING ITEMS

If the criteria for the specific item(s) described above are not met, the item(s) are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

The effectiveness of a powered wheelchair seat cushion (HCPCS code E2610) is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

A seat/back cushion that is provided for use with a transport chair is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

If the individual has a power mobility device with a captain's chair seat, a separate seat and/or back cushion is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

If the individual has a power mobility device with a captain's chair seat, a separate headrest is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

A wheelchair seat or back cushion that does not meet the definition of a specific wheelchair seat or back cushion (HCPCS code K0669) is considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

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 (HCPCS code 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.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, wheelchair cushions and seating items are covered under the medical benefits of the Company’s 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.

A customized item, including an item that is medically necessary, may be a benefit contract exclusion. Individual benefits must be verified.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved numerous cushions and seating items. The FDA considers these devices to be Class I, which are exempt from premarket notification procedures.

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 (e.g., 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.

Types of wheelchair seat cushions and backs, categorized by function, include:
  • General-use seat cushions and backs
    • Provide an alternative to standard sling or solid seats and backs
  • Skin-protection seat cushions
    • Are designed to provide optimal pressure distribution across bony prominences
  • Positioning seat cushions and backs
    • Have features such as pelvic and thigh supports or multiple adjustable air compartments to correct or accommodate postural asymmetries
    • Are contoured and can be adjusted for height and seat-to-back angle
  • Combination skin protection and positioning cushions and backs
    • Offer the features of each type of cushion and back
  • Custom-fabricated seat cushions and backs
    • Provide positioning and/or pressure relief that cannot be met with a prefabricated cushion. They are fabricated using molded-to-patient-model technique, direct-molded-to-patient technique, computer-aided design and manufacturing (CAD-CAM) technology, or detailed measurements of the individual used to create a configured cushion.

Wheelchair positioning components may also be used to promote and maintain proper positioning in the wheelchair. They include, but are not limited to, headrests, trunk supports, lower-extremity supports, and shoulder harnesses.
References


Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33312: Wheelchair Seating. Revised 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Wheelchair+Seating+LCD+and+PA/78eccd60-ce13-40db-8127-a3aec591e176. Accessed August 10, 2017.





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

THE FOLLOWING CODES ARE USED TO REPRESENT WHEELCHAIR CUSHIONS

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


THE FOLLOWING CODES ARE USED TO REPRESENT WHEELCHAIR HEADRESTS

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

THE FOLLOWING CODES ARE USED TO REPRESENT MISCELLANEOUS WHEELCHAIR ACCESSORIES

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

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

E0957 Wheelchair accessory, medial thigh support, any type, 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

K0108 Wheelchair component or accessory, not otherwise specified

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

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

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


Cross References


Policy History

Revisions from 05.00.55i
09/26/2018This policy has been reissued in accordance with the Company's annual review process.
01/01/2018 This 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


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2018
Version Issued Date: 12/29/2017
Version Reissued Date: 09/26/2018

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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.