LCD/NCD Portal

L11523 SEAT LIFT MECHANISMS

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

• For any item to be covered by Medicare, it must

o be eligible for a defined Medicare benefit category

o be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

o Meet all other applicable Medicare statutory and regulatory requirements.

o For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

• For an item addressed in this policy to be covered by Medicare, a written signed and dated order must be received by the supplier prior to delivery of the item.

o If the supplier delivers the item prior to receipt of a written order, it will be denied as noncovered.

o If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained.

o If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

• A seat lift mechanism is covered if all of the following criteria are met:

o The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.

o The seat lift mechanism must be a part of the physician's course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patient's condition.

o The patient must be completely incapable of standing up from a regular armchair or any chair in their home.

 The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism.

 Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.

o Once standing, the patient must have the ability to ambulate.

• Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the patient, and effectively assist a patient in standing up and sitting down without other assistance.

o Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-like motion and jolts the patient from a seated to a standing position.

• The physician ordering the seat lift mechanism must be the treating physician or a consulting physician for the disease or condition resulting in the need for a seat lift.

o The physician’s record must document that all appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the patient to transfer from a chair to a standing position.

 

 

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

CPT/HCPCS Codes

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

 

HCPCS MODIFIER:

 

EY - No physician or other licensed health care provider order for this item or service.

 

HCPCS CODES:

 

E0172 SEAT LIFT MECHANISM PLACED OVER OR ON TOP OF TOILET, ANY TYPE

E0627 SEAT LIFT MECHANISM INCORPORATED INTO A COMBINATION LIFT-CHAIR MECHANISM

E0628 SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELECTRIC

E0629 SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-NON-ELECTRIC

 

 

General Information

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider."

o It is expected that the patient's medical records will reflect the need for the care provided.

o The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

o This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

o Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

• A Certificate of Medical Necessity (CMN), which has been completed, signed and dated by the treating physician, must be kept on file by the supplier, and made available upon request.

o The CMN may act as a substitute for a written order if it contains all of the required elements of an order.

o The CMN for seat lift mechanisms is CMS form 849 (DME form 07.03A).

o The initial claim must include an electronic copy of the CMN.

• Refer to the Supplier Manual for more information on documentation requirements.

 

 

Sources of Information and Basis for Decision

 

A20344 - Seat Lift Mechanisms – Policy Article – Effective September 200

 

 

Seat Lift Mechanisms CMN - CMS 849 (DME MAC 07.03A)

 

 

Local Coverage Determination (LCD) for Seat Lift Mechanisms (L11523)