Clinical UM Guideline
Subject: Lifting Devices for Use in the Home
Guideline #: CG-DME-23 Publish Date: 10/07/2020
Status: Reviewed Last Review Date: 08/13/2020
Description

This document addresses lifting devices for use in the home, including a multi-positional transfer system to assist a caregiver(s) in transferring an individual to and from a bed to a chair (or other locations) when the individual is unable to assist with the transfer.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary:

  1. A hydraulic or mechanical lift is considered medically necessary for an individual when all of the following criteria are met:
    1. When it is used for the transfer of the individual between a bed and a chair, wheelchair, commode, or shower/bath chair; and
    2. When transfers cannot be performed independently and require the assistance of more than one person; and
    3. When the individual would be bed confined without the use of a lift; and
    4. When the individual’s condition is such that periodic movement is necessary to improve his/her condition or to arrest or retard deterioration of their condition.
  2. A canvas or nylon sling or seat for a hydraulic or mechanical lift is considered medically necessary as an accessory when ordered as a replacement for the original equipment item and the criteria listed above are met.
  3. A multi-positional transfer system is considered medically necessary in lieu of any of the following mobility assistive equipment, including but not limited to canes, crutches, walkers, rollabout chairs, transfer chairs, manual wheelchairs, power-operated vehicles, or power wheelchairs, when both of the following criteria are met:
    1. The criteria for a hydraulic or mechanical lift are met; and
    2. The individual requires supine positioning for transfers.

Not Medically Necessary: 

  1. A hydraulic or mechanical lift or multi-positional transfer system is considered not medically necessary when the criteria listed above are not met.
  2. An electric lift mechanism is considered not medically necessary.
Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary or Reconstructive when criteria are met:

HCPCS

 

E0621

Sling or seat, patient lift, canvas or nylon

E0625

Patient lift, bathroom or toilet, not otherwise classified

E0630

Patient lift; hydraulic or mechanical, includes any seat, sling strap(s) or pad(s)

E0636

Multipositional patient support system, with integrated lift, patient accessible controls

E0637

Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels [when used as a lift or transfer system]

E0639

Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories

E0640

Patient lift, fixed system, includes all components/accessories

E1035

Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs

E1036

Multi-positional patient transfer system, extra-wide, with integrated seat, operated by care giver, patient weight capacity greater than 300 lbs

 

 

ICD-10 Diagnosis

 

 

All diagnoses

     

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

When services are also Not Medically Necessary:
For the following procedure codes; or when the code describes a procedure designated in the Clinical Indications section as not medically necessary.

HCPCS

 

E0635

Patient lift; electric, with seat or sling

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

A lift device is used within the home or place of residence to assist the caregiver(s) in transferring an individual between a bed and a chair, wheelchair, commode, or shower/bath chair and back when the individual is unable to assist with the transfer. A multi-positional transfer system is used to assist the caregiver(s) in transferring an individual who requires the use of a lift along with supine positioning for transfer. Multi-positional transfer systems (for example, AryCare Home1000 Patient Lifts, AryLift, Inc., Shallotte, NC; Barton™ Medical Convertible® H-250 Chair Solutions I-400, I-700 & I-1000, Barton Positioning and Transfer System (PTS™), Barton™ Medical Corporation, Austin TX) are intended to facilitate an independent and safe transfer for the caregiver and individuals that have medical conditions that precludes the use of a standard transfer device (that is, a hydraulic or mechanical lift).

The medical necessity of a lift for use in the home setting is based on an evaluation of the individual’s needs and capabilities in relation to the following components of the definition of medical necessity:

  1. Provides therapeutic benefits or enables the individual to perform certain tasks that he or she is unable to undertake otherwise due to certain medical conditions or illnesses; and
  2. Can withstand repeated use; and
  3. Is primarily and customarily used to serve a medical purpose; and
  4. Generally is not useful to a person in the absence of an illness or injury.

Clinical documentation should include the details of the individual’s condition and clearly support the need for the lift device.

An electric lift mechanism is considered not medically necessary as an alternative lift mechanism, as a hydraulic or mechanical lift or multi-positional transfer system is at least as likely to produce equivalent therapeutic results for the treatment of an individual’s illness, injury, or disease.

The following types of lifts and accessories are considered self-help or convenience items and do not meet the definition of durable medical equipment:

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 9, 2020.
Index

AryCare Patient Lifts
Barton Convertible H-250 Chair
Hoyer Lift
Lift-Aid Chamber Lift
Multi-positional Transfer System
Trans-Aid Lift

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

History

Status

Date

Action

Reviewed

08/13/2020

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated Discussion and References sections. Reformatted Coding section.

Reviewed

08/22/2019

MPTAC review. Updated References section.

Reviewed

09/13/2018

MPTAC review. Updated References section.

Reviewed

11/02/2017

MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion, References, and Index sections.

Reviewed

11/03/2016

MPTAC review. Updated formatting in Clinical Indications section. Updated References section.

Reviewed

11/05/2015

MPTAC review. Updated Discussion and References sections. Removed ICD-9 codes from Coding section.

Revised

11/13/2014

MPTAC review. Clarifications to the medically necessary and not medically necessary statements. Updated Description, Discussion, and References sections.

Reviewed

11/14/2013

MPTAC review. Minor format changes to Discussion and Coding sections. Updated Reference section.

Reviewed

11/08/2012

MPTAC review. Updated Discussion, Coding, and References.

Reviewed

11/17/2011

MPTAC review. Updated Discussion and References.

Reviewed

11/18/2010

MPTAC review. Revised title: Lifting Devices for Use in the Home. Updated references.

Reviewed

11/19/2009

MPTAC review. Clarified Clinical Indication for lifts, adding “mechanical” to hydraulic lift statements. Removed Place of Service and Case Management sections, addressing in the Discussion section. Further updates to Discussion and References sections. Updated Coding section to include 01/01/2010 HCPCS changes.

Revised

11/20/2008

MPTAC review. Addition of a medically necessary criteria and not medically necessary indications for a multi-positional transfer system.  Description, Case Management, Discussion, References, Coding and Index updated.

Reviewed

11/29/2007

MPTAC review. Clinical Indications, not medically necessary statement clarified. References and Index updated. Updated Coding section with 01/01/2008 HCPCS changes.

Reviewed

12/07/2006

MPTAC review. References updated.

New

12/01/2005

MPTAC initial document development.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

No Document

Anthem CO/NV

10/29/2004

DME.210

Patient Lifts

Anthem CT

10/01/2004

DME Coverage Criteria Document, Section E

Patient Lifts and Accessories

WellPoint Health Networks, Inc.

 

 

No Document

 

 

 

 


Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

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