Clinical UM Guideline
|Subject:||Lifting Devices for Use in the Home|
|Guideline #:||CG-DME-23||Current Effective Date:||01/13/2015|
|Status:||Revised||Last Review Date:||11/13/2014|
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:
A hydraulic or mechanical lift is considered medically necessary for an individual when all of the following criteria are met:
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.
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:
Not Medically Necessary:
A hydraulic or mechanical lift or multi-positional transfer system is considered not medically necessary when the criteria listed above are not met.
An electric lift mechanism is considered not medically necessary.
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.
|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)|
|E0635||Patient lift; electric, with seat or sling|
|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-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
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, Barton Convertible™ H-250 Chair, 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 (NGS, 2013):
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:
Government Agency, Medical Society, and Other Authoritative Publications:
Barton Convertible H-250 Chair
Lift-Aid Chamber Lift
Multi-positional Transfer System
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 allproducts available.
|Revised||11/13/2014||Medical Policy & Technology Assessment Committee (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.|
Last Review Date
|DME Coverage Criteria Document, Section E||Patient Lifts and Accessories|
|WellPoint Health Networks, Inc.|