L15887 -LCD

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Automated World Health

Local Coverage Determination (LCD) for Wheelchair Seating (L15887)

Contractor Information

Contractor Name CGS Administrators, LLC

Contractor Number 18003

Contractor Type DME MAC

Jurisdiction J - G

LCD Information

Document Information

LCD ID Number L15887

LCD Title Wheelchair Seating

Contractor's Determination Number WCS

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Primary Geographic Jurisdiction

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico South Carolina Tennessee Texas Virginia Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

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 08/05/2011

Revision Ending Date

CMS National Coverage Policy

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 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.

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

For patients who meet coverage criteria for a power wheelchair and who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be covered if either criterion 1 or criterion 2 is met:

1. The cushion is provided with a covered power wheelchair base that is not available in a Captain’s Chair model – i.e., codes K0839, K0840, K0843, K0860 – K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891; or

2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.

If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion will be denied as not reasonable and necessary.

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 reasonable and necessary.

A skin protection seat cushion (E2603, E2604, E2622, E2623) 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:

a. Current pressure ulcer (ICD-9-CM codes 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

b. 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), hemiplegia (342.00 – 342.92, 438.20- 438.22), Huntington's chorea (333.4), idiopathic torsion dystonia (333.6), athetoid cerebral palsy (333.71).

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) due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease (334.0- 334.9), above knee leg amputation (897.2-897.7), osteogenesis imperfecta (756.51), transverse myelitis (323.82).

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 reasonable and necessary.

A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) 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, and if the stated coverage criteria are not met, it will be denied as not reasonable and necessary.

If a positioning back cushion is provided for a patient who does not meet the stated coverage criteria, it will be denied as not reasonable and necessary.

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

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

The effectiveness of a powered seat cushion (E2610) has not been established. Claims for a powered seat cushion will be denied as not reasonable and 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 Pricing, Data Analysis, and Coding (PDAC) contractor or which does not meet the criteria stated in the Coding Guidelines section (see Policy Article) will be denied as not reasonable and necessary.

Coding Information

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 MODIFIERS:

EY – No physician or other licensed healthcare provider order for this item or service

GA - Waiver of liability statement on file issued as required by payer policy, individual case

GY - Item or service statutorily excluded or doesn’t meet the definition of any Medicare benefit category GZ - Item or service expected to be denied as not reasonable and necessary

KX - Requirements specified in the medical policy have been met

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

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

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

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

MISCELLANEOUS:

A9900 MISCELLANEOUS DME SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS CODE

E0992 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT INSERT

E2231 MANUAL WHEELCHAIR ACCESSORY, SOLID SEAT SUPPORT BASE (REPLACES SLING SEAT), INCLUDES ANY TYPE MOUNTING HARDWARE

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 DME PDAC

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, E2622, E2623:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9 opens in

new window 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

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

359.1 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.2 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

707.03 - 707.05 PRESSURE ULCER, LOWER BACK - PRESSURE 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

323.82 OTHER CAUSES OF MYELITIS

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 - 344.32MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

359.1 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.2 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

756.51 OSTEOGENESIS IMPERFECTA

897.2 - 897.7 TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL AT OR ABOVE KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

For HCPCS codes E2607, E2608, E2624, E2625, either

1) One of the following ICD-9 codes:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9 opens in

new window 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

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

359.1 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.2 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

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:

323.82 OTHER CAUSES OF MYELITIS

334.0 - 334.9 FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

438.40 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

756.51 OSTEOGENESIS IMPERFECTA

For HCPCS code E2609:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

323.82 OTHER CAUSES OF MYELITIS

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

PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

335.23 - 335.9

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

359.1 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.2 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

707.03 - 707.05 PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK

741.00 - 741.93 SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

756.51 OSTEOGENESIS IMPERFECTA

For HCPCS codes E0955, E2601, E2602, E2611, E2612 and E2619:

Not Specified

For codes E2610, and K0669: None

AsteriskNoteText

Diagnoses that Support Medical Necessity Refer to previous section.

ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section.

For HCPCS codes E2610 and K0669: All ICD-9 codes

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS codes indicated above, all diagnoses that are not specified in the previous section.

For HCPCS codes E2610 and K0669: All diagnoses.

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

For cushions and positioning accessories provided at the time of initial issue of a power wheelchair, once the supplier has determined the specific power mobility device that is appropriate for the patient based on the physician's 7-element order, the supplier must prepare a written document (termed a detailed product description). This detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in the Supplier Manual and CMS’ Program Integrity Manual (Internet-Only Manual, Pub. 100-8), Chapter 5. Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.

The physician must sign and date the detailed product description and the supplier must receive it prior to delivery of the PWC or POV. A date stamp or equivalent must be used to document the supplier receipt date. The detailed product description must be available on request.

For items provided for a power mobility device other than at the time of initial issue, there must be a detailed written order which is signed and dated by the physician. This order must be received by the supplier prior to delivery.

For cushions and positioning accessories provided for a manual wheelchair, there must be a detailed written order which is signed and dated by the physician. This order must be received by the supplier prior to delivery of the item.

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.

The ICD-9 code which justifies the need for these items must be included on the claim.

KX MODIFIER:

For a skin protection seat cushion (E2603, E2604, E2622, E2623), a KX modifier must be added to the code only if either criterion (a), (b), or (c) is met:

a. If there is a past history of or current pressure ulcer in the area of contact with the seating surface; or

b. If there is absent or impaired sensation in the area of contact with the seating surface due to one of the diagnoses listed as a covered diagnosis; or

c. If there is an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis.

For a positioning seat cushion (E2605, E2606), positioning back cushion (E2613-E2616, E2620, E2621), or positioning accessory (E0956-E0957, E0960), a KX modifier must be added to the code only if the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis.

For a headrest (E0955), a KX modifier must be added to the code only if one of the coverage criteria specified in the Indications and Limitations of Coverage section has been met.

For a combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625), a KX modifier must be added to the code only if criterion (a) or (b) or (c) is met and criterion (d) is met

a. If there is a past history or current pressure ulcer in the area of contact with the seating surface; or

b. If there is absent or impaired sensation in the area of contact with the seating surface due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); or

c. If there is an inability to carry out a functional weight shift due one of the diagnoses listed as a covered diagnosis for skin protection cushions (except 707.03, 707.04, 707.05); and

d. If the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

For a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added to the code only if criterion (a) is met and criterion (b), (c), or (d) is met:

a. For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a prefabricated seating system is not sufficient to meet the patient’s seating and positioning needs; and

b. For E2609, there is a past history of or current pressure ulcer in the area of contact with the seating surface; or

c. For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin protection cushions; or

d. For E2609 or E2617, the patient has significant postural asymmetries due to one of the diagnoses listed as a covered diagnosis for positioning cushions.

In addition to meeting the specific requirements listed above, for all seat and back cushions and positioning accessories, the KX modifier must be added to the code only if the item is being used with a wheelchair that meets coverage criteria specified in the Manual Wheelchair Bases or Power Mobility Devices LCD.

GA GY, AND GZ MODIFIERS:

For a cushion or positioning accessory that is used with a power mobility device, if the requirements related to a

7-element order and face-to-face examination in the Power Mobility Devices Policy Article have not been met, the GY modifier must be added to the codes for all items.

For items provided with a manual wheelchair or power mobility device, if it is only needed for mobility outside the home, the GY modifier must be added to the codes for all items.

In all of the situations above describing use of the KX modifier, if all of the specific coverage criteria have not been met or if the wheelchair that it is being used with does not meet the coverage criteria in the Manual Wheelchair Bases or Power Mobility Devices LCD, the GA or GZ modifier must be added to a claim line for the seat or back cushion or positioning accessory. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

If the GY modifier is used, the KX, GA, and GZ modifiers should not be used.

Claim lines billed without a GA, GY, GZ, or KX modifier will be rejected as missing information.

MISCELLANEOUS:

When billing for a custom fabricated cushion (E2609, E2617), the claim must include the manufacturer and model name/ number of the product (if applicable), or if not, a detailed description of the product that was provided.

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

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision Advisory Committee Meeting Notes

Start Date of Comment Period 12/03/2001

End Date of Comment Period 01/21/2002

Start Date of Notice Period 03/01/2004

Revision History Number 012

Revision History Explanation Revision Effective Date: 06/01/2011 DOCUMENTATION REQUIREMENTS:

Revised: Language for detailed product description

Revision Effective Date: 02/04/2011 INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Least costly alternative language for general use cushions used with power wheelchairs with sling/solid seats/backs, for skin protection, positioning and combination seat cushions, for positioning back cushions, and for custom fabricated cushions.

HCPCS CODES AND MODIFIERS: (Effective 1/1/2011) Added: E2622-E2625

Revised: GA

Deleted: K0734–K0737

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY: (Effective 1/1/2011)

Replaced: K0734-K0737 with E2622-E2625 DOCUMENTATION REQUIREMENTS: (Effective 1/1/2011)

Replaced: K0734-K0737 with E2622-E2625

11/21/2010 - The following CPT/HCPCS codes were deleted: K0734 was deleted from Group 1

K0735 was deleted from Group 1 K0736 was deleted from Group 1 K0737 was deleted from Group 1

06/26/2010 - The description for CPT/HCPCS code K0669 was changed in group 4 Revision Effective Date: 04/01/2010

HCPCS CODES AND MODIFIERS:

Added: GY Revised: GA

DOCUMENTATION REQUIREMENTS:

Added: Requirements for use of the GY modifier Revised: Requirements for detailed product description Revised: Requirements for use of the KX modifier Revised: Requirements for use of GA and GZ modifiers

Revision Effective Date: 12/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Hemiplegia, Huntington’s chorea, idiopathic torsion dystonia, and cerebral palsy to the list of covered conditions for skin protection seat cushions

Added: above knee amputations, osteogenesis imperfecta, and transverse myelitis to the list of covered conditions for positioning seat and back cushions and positioning accessories

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Added: Corresponding ICD-9 codes

Moved: 359.0, 359.1 from second group of codes to the first group of codes for E2607, E2608, K0736, K0737 HCPCS MODIFIERS:

Added: GA, GZ Revised: KX modifier

DOCUMENTATION REQUIREMENTS:

Added: Instructions for use of GA and GZ modifiers

Revision Effective Date: 01/01/2009 INDICATIONS AND LIMITATIONS OF COVERAGE:

Replaced: Reference to SADMERC with PDAC HCPCS CODES AND MODIFIERS:

Added: E2231 Revised: K0669

11/09/2008 -The description for CPT/HCPCS code K0669 was changed in group 4

Revision Effective Date: 08/10/2008 - This policy was updated by the ICD-9 2008-2009 Annual Update. 03/01/2008 - In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to

DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 01/01/2008

INDICATIONS AND LIMITANTIONS OF COVERAGE:

Added: Muscular dystrophy to the list of covered diagnoses for prefabricated skin protection and combination skin protection and positioning seat cushions.

Removed: Instructions concerning solid seat support base (E2618)

HCPCS CODES AND MODIFIERS:

Added: K0108 Deleted: E2618

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Added: Muscular dystrophy (359.0, 359.1) to the list of covered diagnoses for prefabricated skin protection and combination skin protection and positioning seat cushions.

Removed: E2618

Revision Effective Date: 07/01/2007 CODING INFORMATION:

Update: Description of K0737

INDICATONS AND LIMITATIONS OF COVERAGE:

Removed: DMERC references

06/01/2007 - In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 11/15/2006

Implementation of the 10/01/2006 LCD revision has been delayed. DOCUMENTATION REQUIREMENTS:

Revised: Instructions for detailed product description.

Revision Effective Date: 10/01/2006 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: Least costly alternative statement regarding general use cushions.

Revised: Coverage criteria for all seat/back cushions and positioning accessories to identify their coverage with specific types of power mobility devices.

Revised: Statement concerning coverage of a headrest.

Revised: Wording which describes the clinician who performs the evaluation for a custom fabricated cushion. Added: A statement concerning coverage of a seat cushion solid support base (E2618).

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Substituted: ICD-9 333.71 for 333.7 in three of the diagnosis sets. DOCUMENTATION REQUIREMENTS:

Added: Requirement for detailed product description for items provided at the time of issue of a power wheelchair.

Revised: Wording which describes the clinician who performs the evaluation for a custom fabricated cushion.

Revision Effective Date: 07/01/2006 INDICATIONS AND LIMITATIONS OF COVERAGE:

Substituted: new codes for adjustable seat cushions. HCPCS CODES:

Added: K0734, K0735, K0736, K0737

Discontinued: K0108

ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:

Substituted: New codes for adjustable seat cushions.

Corrected: By substituting K0669 for E2619 and deleting A9900 in last group ICD-9 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:

Corrected: By substituting K0669 for E2619.

DIAGNOSES THAT DO NOT SUPPORT MEDICAL NECESSITY:

Corrected: By substituting K0669 for E2619. DOCUMENTATION REQUIREMENTS:

Substituted: New codes for adjustable seat cushions. Removed: Claim submission requirements for K0108.

03/01/2006 - In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 10/01/2005 INDICATIONS AND LIMITATIONS OF COVERAGE

Revised: Coverage criteria for headrests (E0955) ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY

Eliminated: Listing of ICD-9 codes for headrests DOCUMENTATION REQUIREMENTS

Revised: KX modifier requirements for headrests

Eliminated: Statement that additional documentation may be submitted with a claim if the KX modifier is not used

SOURCES OF INFORMATION AND BASIS FOR DECISION

Deleted: List of references

Revision Effective Date: 04/01/2005 HCPCS CODES AND MODIFIERS: Added: E2291-E2294

Revision Effective Date: 01/01/2005 INDICATIONS AND LIMITATIONS OF COVERAGE:

Added: References to codes E2620, E2621 Replaced: K codes with new E codes

Added: Statements related to adjustable seat cushions HCPCS CODES:

Added: Codes E2620, E2621, E2618, E2619

Replaced: K codes with new E codes (E2601-E2617, E2619) ICD-9 CODES SUPPORTING MEDICAL NECESSITY:

Added: Codes E2620, E2621 Replaced: K codes with new E codes

Corrected: The diagnosis set for codes E2607 and E2608 Added: Statements related to adjustable seat cushions DOCUMENTATION REQUIREMENTS:

Added: References to codes E2620, E2621 Replaced: K codes with new E codes

Revised: Ttem (d) under the KX modifier requirements for codes E2607 and E2608 Added: Statements related to adjustable seat cushions

Added: Claim submission requirements for custom fabricated cushions Revised: The claim submission requirements for K0108

Revision Effective Date: 10/01/2004 INDICATIONS AND LIMITATIONS OF COVERAGE:

Revised: Acceptable diagnosis codes for decubitus ulcers ICD-9 CODES SUPPORTING MEDICAL NECESSITY:

Changed: Acceptable ICD-9 codes for decubitus ulcers from 707.0 to 707.03, 707.04, 707.05

Corrected: The diagnosis set for K0658 to match the narrative description in the Indications and Limitations of Coverage section

DOCUMENTATION REQUIREMENTS:

Revised: General requirements in paragraph 1 Corrected: The code range for positioning accessories Revised: Acceptable diagnosis codes for decubitus ulcers

Revision Effective Date: 07/01/2004 HCPCS CODES: Added E0966

Documentation Requirements: Revised the criteria or use of the KX modifier for combination and skin protection and postioning seat cushions.

08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)