Clinical UM Guideline
Subject: Seat Lift Mechanisms
Guideline #: CG-DME-25 Publish Date: 10/07/2020
Status: Revised Last Review Date: 08/13/2020
Description

This document addresses seat lift mechanisms, assistive devices used in the home to lift a person’s body from a sitting position to a standing position or to lower the individual from a standing to a sitting position.

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

Clinical Indications

Medically Necessary:

A seat lift mechanism is considered medically necessary when all the following criteria are met:

  1. The individual must have severe arthritis of the hip or knee(s) or have a severe neuromuscular disease; and
  2. The seat lift mechanism must be a part of the prescribed course of treatment; and
  3. The individual must be completely incapable of standing up from a regular armchair or any chair in their home; and
  4. Once standing, the individual must have the ability to ambulate.

Note: Documentation that an individual has difficulty or is even incapable of getting up from a chair, particularly a low chair, is insufficient justification for a seat lift mechanism. Most individuals who are capable of ambulating can raise up out of an ordinary chair if the seat height is appropriate and the chair has arms.

Not Medically Necessary:

  1. A seat lift that operates by spring release mechanism with a sudden, catapult-like motion and jolts the individual from a seated to a standing position is considered not medically necessary.
  2. A seat lift mechanism is considered not medically necessary when the criteria listed above are not met.
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 when criteria are met:

HCPCS

 

E0170

Commode chair with integrated seat lift mechanism, electric, any type

E0171

Commode chair with integrated seat lift mechanism, non-electric, any type

E0172

Seat lift mechanism placed over or on top of toilet, any type

E0627

Seat lift mechanism, electric, any type

E0629

Seat lift mechanism, non-electric, any type

 

 

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.

Discussion/General Information

Individuals with impaired mobility often require physical assistance in lifting and transferring. Numerous medical conditions (such as, arthritis, muscular dystrophy, and neuromuscular diseases) can lead to limited mobility as a result of pain, joint stiffness or muscle weakness. Individuals are often not able to move from a sitting position to a standing position without the assistance of another person or a device. Devices such as seat lift mechanisms have been employed to ease transfers and prevent injuries to the individual, caregiver, or both (CMS, 2005). These devices are utilized in the individual’s home or place of residence. In establishing medical necessity for the seat lift, CMS states the seat lift must be included in the physician's course of treatment, that it is likely to affect improvement or arrest or retard deterioration in the individual's condition, and that the severity of the condition is such that the alternative would be chair or bed confinement (CMS, 1989).

References

Peer Reviewed Publications:

  1. Edlich RF, Heather CL, Galumbeck MH. Revolutionary advances in adaptive seating systems for the elderly and persons with disabilities that assist sit-to-stand transfers. J Long Term Eff Med Implants. 2003; 13(1):31-39.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on June 24, 2020.
History

Status

Date

Action

Revised

08/13/2020

Medical Policy & Technology Assessment Committee (MPTAC) review. In criterion two of the Clinical Indications section, changed the word “physician’s” to “prescribed” and removed the statement “and be prescribed to effect improvement or arrest or retard deterioration in the individual’s condition.” Updated References sections. Reformatted Coding section.

Reviewed

08/22/2019

MPTAC review. Updated Discussion/General Information and References sections.

Reviewed

09/13/2018

MPTAC review. Updated Discussion and References sections.

Reviewed

11/02/2017

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

Reviewed

11/03/2016

MPTAC review. Updated formatting in the Clinical Indications section. Updated References section. Updated Coding section with 01/01/2017 HCPCS changes including descriptor changes for E0627, E0629.

Reviewed

11/05/2015

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

Reviewed

11/13/2014

MPTAC review. Updated Description section.

Reviewed

11/14/2013

MPTAC review. Format change to Coding section. Updated Discussion and References sections.

Reviewed

11/08/2012

MPTAC review. Updated References and removed/deleted Index.

Reviewed

11/17/2011

MPTAC review. Updated Coding and References.

Reviewed

11/18/2010

MPTAC review. Updated References.

Reviewed

11/19/2009

MPTAC review. Removed Place of Service and Discharge Plans. Updated Discussion, Coding and References.

Revised

11/20/2008

MPTAC review. Added a not medically necessary indication: A seat lift mechanism is considered not medically necessary when the criteria listed above are not met. Discussion and References updated.

Reviewed

11/29/2007

MPTAC review. References updated.

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.

 

None

 

Anthem CT

 

DME

Seat Lift Mechanisms

Anthem West (CO/NV)

10/29/2004

DME.209

Seat Lift Mechanisms

WellPoint Health Networks, Inc.

 

None

 

 

 

 

 


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.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

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