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LCD - Wheelchair Seating

Coverage Summary

Cushions listed are only covered if a patient has a manual wheelchair or power wheelchair with a sling/solid seat/back which meets coverage criteria.

  • General use cushion and back patient must have a manual wheelchair or power wheelchair with a sling/solid seat/back which meets coverage criteria.
  • Skin protection seat cushion is covered for a patient who has current or past history of pressure ulcer, absent or impaired sensation with the seating surface or inability to carry out a functional weight shift due to: spinal cord injury resulting in quadriplegia or paraplegia, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease,muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease or transverse myelitis.
  • Positioning Seat Cushion is covered for a patient who has significant postural asymmetries that are due to one of the diagnoses listed in the above skin protection detail or monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis.
  • Combination skin protection and positioning seat cushion is covered for a patient who meets the criteria for both a skin protection cushion and positioning cushion.

Order Requirements

  • DME Order Form
  • Dr. must be PECOS registered for all Medicare orders.

  1. Patient Name
  2. Specific description of ordered items to be delivered
  3. Length of Medical Need (ie, lifetime or other)
  4. Ordering Physician’s NPI
  5. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  6. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance.)
  7. Start date of the order – if different than signature date.

Coverage Detail

General Use seat cushion and back:

  • A general use seat cushion and a general use wheelchair back cushion is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets coverage criteria. If the beneficiary does not have a covered wheelchair, then the cushion will be denied as not reasonable and necessary.

Skin Protection Seat Cushion:

  1. A skin protection seat cushion is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the meets coverage criteria for it; and has either of the following:
  2. Current pressure ulcer or past history of a pressure ulcer (see diagnosis codes that support medical necessity section below) on the area of contact with the seating surface; or
  3. 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, other spinal cord disease, multiple sclerosis, other demyelinating disease, cerebral palsy, anterior horn cell diseases including amyotrophic lateral sclerosis, post polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease,muscular dystrophy, hemiplegia, Huntington's chorea, idiopathic torsion dystonia, athetoid cerebral palsy, arthrogryposis, osteogenesis imperfecta, spinocerebellar disease or transverse myelitis.

Positioning Seat Cushion:

  • A positioning seat cushion, positioning back cushion, and positioning accessory cushion is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the meets coverage criteria for it; and meets the following criteria:

  • The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 3 above or to one of the following diagnoses: monoplegia of the lower limb due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease, above knee leg amputation, osteogenesis imperfecta, transverse myelitis.

Combination Skin Protection and Positioning Seat Cushion:

  • A combination skin protection and positioning seat cushion is covered for a patient who has a manual wheelchair or a power wheelchair with a sling/solid seat/back and who meets the criteria for both a skin protection seat cushion and a positioning seat cushion.

NOTE:

  • The patient must have a manual wheelchair or a power wheelchair with a sling/solid seat/back that meets coverage criteria.

  • The patient’s medical record must include the height and weight in order to select the proper equipment to meet the patient’s need.

  • If patient has existing equipment, provider must know specific dimensions of equipment in order to properly fit a cushion.