MA PPO
Advanced Search

Wheelchair Cushions and Seating
05.00.55l

​

Policy

MEDICALLY NECESSARY

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 cr​iteria apply. These items are included in the following sections.​

GENERAL-USE SEAT CUSHIONS AND BACK CUSHIONS
General-use seat cushions and general-use wheelchair back cushions are considered medically necessary and, therefore, covered when the individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair with a sling​, 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).

POWER-OPERATED VEHICLE (POV) OR POWER WHEELCHAIR
POVs or power wheelchairs with a captain chair is considered medically necessary and, therefore, covered for an individual who needs appropriate support but does not have special skin protection or positioning needs.

General-use cushions are considered medically necessary and, therefore, covered for an individual who has a power wheelchair with a sling, solid seat or back, instead of a captain chair, when either of the following criteria is met:​
  • The cushion is provided with a medically necessary power wheelchair base that is not available in a captain chair model.
  • A skin protection and/or positioning seat or back cushion is provided that meets the medical necessity criteria.​
SKIN PROTECTION SEAT CUSHIONS (ADJUSTABLE AND NONADJUSTABLE)
Skin protection seat cushions are considered medically necessary and, therefore, covered when the individual meets ​both of the following criteria: 
  • The individual meets all of the medical necessity criteria for a manual wheelchair or a power wheelchair with a sling, solid seat, or back.
  • The individual has either of the following: 
    • Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface
    • Absent or impaired sensation in the area where the 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 (ALS)
      • Arthrogryposis
      • Athetoid cerebral palsy
      • Cerebral palsy
      • Childhood cerebral degeneration
      • Demyelinating diseases (e.g., progressive multifocal leukoencephalopathy, leukodystrophies)
      • Hemiplegia
      • Huntington’s chorea
      • Idiopathic torsion dystonia
      • Multiple sclerosis
      • Muscular dystrophy
      • 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, positioning back cushions, and positioning accessories are considered medically necessary and, therefore, covered when the individual meets both of the following criteria: 
  • The individual meets all of the medical necessity criteria for a manual wheelchair or power wheelchair that has a sling, solid seat or back
  • ​The individual has significant postural asymmetries that are due to one of the following conditions:
      • Above-knee leg amputation
      • Alzheimer’s disease
      • Anterior horn cell diseases including ALS
      • Athetoid cerebral palsy
      • Cerebral palsy
      • Childhood cerebral degeneration
      • Demyelinating disease (e.g., progressive multifocal leukoencephalopathy, leukodystrophies)
      • 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
      • 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
COMBINATION SKIN PROTECTION AND POSITIONING SEAT CUSHIONS (ADJUSTABLE AND NONADJUSTABLE)​
Combination s​kin protection and positioning seat cushions are considered medically necessary and, therefore, covered when the individual ​​meets the medical necessity criteria for both a skin protection seat cushion and a positioning seat cushion.

CUSTOM-FABRICATED SEAT CUSHIONS
Custom-fabricated seat cushions are considered medically necessary and, therefore, covered when both of the following criteria are met:
  • 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
Custom-fabricated back cushions are considered medically necessary and, therefore, covered when both of the following criteria are met:​
  • The individual meets all of the medical necessity​ 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
Headrests and headrest extensions are considered medically necessary and, therefore, covered when the individual has a medically necessary, manual tilt-in-space, manual semi- or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or a power tilt and/or recline power seating system.

NOT MEDICALLY NECESSARY

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.

If the individual does not have a medically necessary wheelchair, then the cushion(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.

In addition, the following wheelchair cushion and seating​ items 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:
  • A powered wheelchair seat cushion
  • A seat/back cushion that is provided for use with a transport chair
  • A separate seat, back cushion, ​headrest, and/or other positioning accessory when the individual has a power mobility device with a captain chair seat
  • A wheelchair seat or back cushion that does not meet the definition of a specific wheelchair seat or back cushion​​
ADDITIONAL REIMBURSEMENT CONSIDERATIONS

The code for a seat or back cushion includes any rigid or semi-rigid base or posterior panel, respectively, that is an integral part of the cushion.​
​​​
A solid base is included in the allowance for a wheelchair seat/back cushion; therefore, a solid insert 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.
​

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.

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY REQUIREMENTS
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 durable medical equipment (DME) supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The 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 7 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 5 days before the individual would exhaust their on-hand supply.

For specified DME items, 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 DME supplier may be required to reimburse the Company for overpayments.​


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 DME.

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 (e.g., 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 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 custom-fabricated back cushions
    • 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.
    • Are individually made for a specific individual starting with basic materials including liquid foam or a block of foam and sheets of fabric- or liquid-coating material.​
A lateral contour is a backward curve measured from a horizontal line connecting the lateral extensions of the cushion; for posterior pelvic cushions, there is mounting hardware that is adjustable for vertical position, depth, and angle. A lateral contour has a removable vapor-permeable or waterproof cover, or it has a waterproof surface, a permanent label indicating the model and the manufacturer; and a warranty that provides for repair or full replacement if manufacturing defects are identified or the surface does not remain intact due to normal wear within 18 months. Included in this definition of a lateral contour are cushions that have a planar surface but have positioning features within the cushion that are made of a firmer material than the surface material.

The cushion must have structural features that significantly exceed the minimum requirements for a seat or back positioning cushion. The cushion must have a removable vapor-permeable or a waterproof cover or it must have a waterproof surface. A custom-fabricated cushion may include certain prefabricated components (e.g., gel or multicellular air inserts). 

A powered wheelchair seat cushion is a battery-powered, prefabricated cushion in which an air pump provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the cushion. One type of powered seat cushion is an alternating pressure 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

Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; End-stage renal disease prospective payment system, payment for renal dialysis services furnished to individuals with acute kidney injury, end-stage renal disease quality incentive program, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) fee schedule amounts, DMEPOS competitive bidding program (CBP) amendments, standard elements for a DMEPOS order, and master list of DMEPOS items potentially subject to a face-to-face encounter and written order prior to delivery and/or prior authorization requirements for calendar year (CY) 2022; Final Rule. [Federal Register Web site]. 01/01/2022. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Downloads/FINAL-RULE-MASTER-LIST-of-DMEPOS-Subject-to-Frequent-Unnecessary-Utilization-2018-03-30.pdf. Accessed May 26, 2023.


Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. Final Rule. [Federal Register Web site]. 01/17/2023. Available at: https://www.federalregister.gov/documents/2023/01/17/2023-00718/medicare-program-updates-to-face-to-face-encounter-and-written-order-prior-to-delivery-list. Accessed May 26, 2023.

 
Noridian Healthcare Solutions. Local Coverage Article (A52505). Wheelchair Seating. [Noridian Web site]. Original 10/01/2015. (Revised:10/01/2022). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52505. Accessed May 26, 2023.


Noridian Healthcare Solutions. Local Coverage Determination (L33312). Wheelchair Seating. [Noridian Web site]. Original 10/01/15. (Revised: 01/01/2020). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33312&ContrId=389. Accessed May 26, 2023.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
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, other

E1032 Wheelchair accessory, manual swingaway, retractable or removable hardware used with joystick or other drive control interface

E1033 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type

E1034 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type
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

Policy History

Revisions From 05.00.55l:​
04/01/2025 

This policy has been identified for a HCPCS code update effective 04/01/2025.

The following HCPCS code narrative has been revised this policy:

Changed from: E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
Changed to: E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware, other


The following HCPCS codes have been added to the policy: 

E1032 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware used with joystick or other drive control interface

E1033 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type

 

E1034 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type ​


Revisions From 05.00.55k:
​06/26/2024
​This policy has been reviewed in accordance with the Company's annual review process.
08/14/2023
​This version of the policy will become effective 08/14/2023.

Face-to-Face Requirement language has been removed for HCPCS codes E2613, E2614, E2616, E2620, and E2621 in accordance with the 2023 CMS New Final Rule on the Face-to-Face Encounters.  

Revisions From 05.00.55j:
​08/15/2022
​This version of the policy will become effective 08/15/2022.


Face-to-Face Requirement language has been added for the following HCPCS codes: ​

  • 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
  • E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 in or greater, any height, including any type mounting hardware
  • 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​

​The following medically necessity criteria have been added to this policy:​

  • ​General use cushion for power wheelchairs
  • Captains Chair for power wheelchairs​


Revisions From 05.00.55i:​
10/06/2021
​​The policy has been reviewed and reissued to communicate the Company's continuing position on Wheelchair Cushions and Seating.​​
12/16/2020
​The policy has been reviewed and reissued to communicate the Company's continuing position on Wheelchair Cushions and Seating.​
06/05/2019The policy has been reviewed and reissued to communicate the Company's continuing position on Wheelchair Cushions and Seating.
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.
4/1/2025
4/1/2025
05.00.55
Medical Policy Bulletin
Commercial
No
Connect with Us

2025 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.