LCD for Wheelchair Seating (L15845)

 

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Contractor Information

Contractor Name 

NHIC 

Contractor Number 

16003 

Contractor Type 

DME MAC 

 

LCD Information

LCD ID Number 

L15845 

 

LCD Title 

Wheelchair Seating 

 

Contractor's Determination Number 

WCS20080101 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.  

 

CMS National Coverage Policy 

 

 

Primary Geographic Jurisdiction 

Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York - Entire State
Pennsylvania
Rhode Island
Vermont
 

 

Oversight Region 

Region III
 

 

 

DME Region LCD Covers 

Jurisdiction A 

 

Original Determination Effective Date 

For services performed on or after 07/01/2004  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 01/01/2008  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

For any item to be covered by Medicare, it must: 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, "reasonable and necessary" is defined by the following indications and limitations of coverage and/or medical necessity.

A general use seat cushion (E2601,E2602) and a general use wheelchair back cushion (E2611-E2612) is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the patient does not have a covered wheelchair, then the cushion will be denied as not medically necessary. If the patient has a POV or a power wheelchair with a captain's chair seat, the cushion will be denied as not medically necessary.

If a general use seat and/or back cushion is provided with a power wheelchair with a sling/solid seat/back, total payment for those items (cushion(s) plus the wheelchair) will be based on the allowance for the least costly medically appropriate alternative – e.g., the code for the comparable power wheelchair with Captain's Chair, if that code exists. (See Power Mobility Device policy for additional information.)

If the patient has a POV or a power wheelchair with a captain's chair seat, a separate seat and/or back cushion will be denied as not medically necessary.

A skin protection seat cushion (E2603, E2604, K0734, K0735) is covered for a patient who meets both of the following criteria:

 

  1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
  2. The patient has either of the following:

 

    1. Current pressure ulcer (707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface; or
    2. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury resulting in quadriplegia or paraplegia (344.00-344.1), other spinal cord disease (336.0-336.3), multiple sclerosis (340), other demyelinating disease (341.0-341.9), cerebral palsy (343.0-343.9), anterior horn cell diseases including amyotrophic lateral sclerosis (335.0-335.21, 335.23-335.9), post polio paralysis (138), traumatic brain injury resulting in quadriplegia (344.09), spina bifida (741.00-741.93), childhood cerebral degeneration (330.0-330.9), Alzheimer's disease (331.0), Parkinson's disease (332.0),muscular dystrophy (359.0, 359.1).



A positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) is covered for a patient who meets both of the following criteria:

 

  1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and
  2. The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) or hemiplegia (342.00-342.92, 438.20-438.22) due to stroke, traumatic brain injury, or other etiology, torsion dystonias (333.4, 333.6, 333.71), spinocerebellar disease (334.0-334.9).



A headrest (E0955) is also covered when the patient has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.

If the patient has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will be denied as not medically necessary.

A combination skin protection and positioning seat cushion (E2607, E2608, K0736, K0737) is covered for a patient who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for a another type of seat cushion are not met, the provided cushion will be denied as not medically necessary.

If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for a general use back cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative, E2611 or E2612; if the criteria for a general use back cushion are not met, the provided cushion will be denied as not medically necessary.

If a positioning accessory is provided and the criteria are not met, the item will be denied as not medically necessary.

A custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met:

 

  1. Patient meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;
  2. Patient meets all of the criteria for a prefabricated positioning back cushion;
  3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs. The PT or OT may have no financial relationship with the supplier.



If a custom fabricated cushion is provided for a patient who does not meet the stated coverage criteria, but the coverage criteria for another type of cushion are met, payment will be based on the allowance for the least costly medically appropriate alternative; if the criteria for another type of cushion are not met, the custom fabricated cushion will be denied as not medically necessary.

A seat or back cushion that is provided for use with a transport chair (E1037, E1038) will be denied as not medically necessary.

The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied as not medically necessary.

A prefabricated seat cushion, a prefabricated positioning back cushion, or a brand name custom fabricated seat or back cushion which has not received a written coding verification from the SADMERC or which does not meet the criteria stated in the Coding Guidelines section (see Policy Article) will be denied as not medically necessary. 

 

Coverage Topic 

Durable Medical Equipment
Wheelchairs
 

 

Coding Information

CPT/HCPCS Codes 

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY - No physician or other licensed healthcare provider order for this item or service
KX - Specific required documentation on file
HCPCS CODES:

SEAT CUSHIONS:


E2601

GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

E2602

GENERAL USE WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

E2603

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

E2604

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

E2605

POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

E2606

POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

E2607

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH LESS THAN 22 INCHES, ANY DEPTH

E2608

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, WIDTH 22 INCHES OR GREATER, ANY DEPTH

E2609

CUSTOM FABRICATED WHEELCHAIR SEAT CUSHION, ANY SIZE

E2610

WHEELCHAIR SEAT CUSHION, POWERED

K0734

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

K0735

SKIN PROTECTION WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

K0736

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH LESS THAN 22 INCHES, ANY DEPTH

K0737

SKIN PROTECTION AND POSITIONING WHEELCHAIR SEAT CUSHION, ADJUSTABLE, WIDTH 22 INCHES OR GREATER, ANY DEPTH

HCPCS CODES:

BACK CUSHIONS:

E2611

GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2612

GENERAL USE WHEELCHAIR BACK CUSHION, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2613

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2614

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2615

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2616

POSITIONING WHEELCHAIR BACK CUSHION, POSTERIOR-LATERAL, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2617

CUSTOM FABRICATED WHEELCHAIR BACK CUSHION, ANY SIZE, INCLUDING ANY TYPE MOUNTING HARDWARE

E2620

POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH LESS THAN 22 INCHES, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

E2621

POSITIONING WHEELCHAIR BACK CUSHION, PLANAR BACK WITH LATERAL SUPPORTS, WIDTH 22 INCHES OR GREATER, ANY HEIGHT, INCLUDING ANY TYPE MOUNTING HARDWARE

HCPCS CODES:

POSITIONING ACCESSORIES:

E0955

WHEELCHAIR ACCESSORY, HEADREST, CUSHIONED, ANY TYPE, INCLUDING FIXED MOUNTING HARDWARE, EACH

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

E1028

WHEELCHAIR ACCESSORY, MANUAL SWINGAWAY, RETRACTABLE OR REMOVABLE MOUNTING HARDWARE FOR JOYSTICK, OTHER CONTROL INTERFACE OR POSITIONING ACCESSORY

HCPCS CODES:

MISCELLANEOUS:

A9900

MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE

E0992

MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

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

E2619

REPLACEMENT COVER FOR WHEELCHAIR SEAT CUSHION OR BACK CUSHION, EACH

K0108

WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED

K0669

WHEELCHAIR ACCESSORY, WHEELCHAIR SEAT OR BACK CUSHION, DOES NOT MEET SPECIFIC CODE CRITERIA OR NO WRITTEN CODING VERIFICATION FROM SADMERC

 

 

ICD-9 Codes that Support Medical Necessity 

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on Indications and Limitation of Coverage and/or Medical Necessity for other coverage criteria and payment information.

For HCPCS codes E2603, E2604, K0734, K0735:

138

LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9

LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0

ALZHEIMER'S DISEASE

332.0

PARALYSIS AGITANS

335.0 - 335.21

WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9

PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3

SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340

MULTIPLE SCLEROSIS

341.0 - 341.9

NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

343.0 - 343.9

CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1

QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

359.0

CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1

HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

707.03 - 707.05

DECUBITUS ULCER, LOWER BACK - DECUBITUS ULCER, BUTTOCK

741.00 - 741.93

SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

For HCPCS codes E0956-E0957, E0960, E2605, E2606, E2613-E2617, E2620, and E2621:


138

LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9

LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0

ALZHEIMER'S DISEASE

332.0

PARALYSIS AGITANS

333.4

HUNTINGTON'S CHOREA

333.6

GENETIC TORSION DYSTONIA

333.71

ATHETOID CEREBRAL PALSY

334.0 - 334.9

FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

335.0 - 335.21

WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9

PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3

SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340

MULTIPLE SCLEROSIS

341.0 - 341.9

NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

342.00 - 342.92

FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

343.0 - 343.9

CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1

QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

344.30 - 344.32

MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

359.0

CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1

HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22

HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.40 - 438.42

MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

741.00 - 741.93

SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

For HCPCS codes E2607, E2608, K0736, K0737, either 1) One of the following ICD-9 codes:

138

LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9

LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0

ALZHEIMER'S DISEASE

332.0

PARALYSIS AGITANS

335.0 - 335.21

WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9

PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3

SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340

MULTIPLE SCLEROSIS

341.0 - 341.9

NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

343.0 - 343.9

CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1

QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

741.00 - 741.93

SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

Or 2) A combination of ICD-9 code 707.03, 707.04, or 707.05 AND one of the following ICD-9 codes:

333.4

HUNTINGTON'S CHOREA

333.6

GENETIC TORSION DYSTONIA

333.71

ATHETOID CEREBRAL PALSY

334.0 - 334.9

FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

342.00 - 342.92

FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

344.30 - 344.32

MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

359.0

CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1

HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22

HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.40 - 438.42

MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

For HCPCS code E2609


138

LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9

LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD