Appeal type: unknown
Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such a grab bars. You 
can find these rules in the Medicare Benefit Policy Manual, Chapter 15, Section 110.1.  
 
The rules say that a seat lift mechanism is covered if all of the following criteria are met: 
 
    1. The beneficiary must have severe arthritis of the hip or knee or have a severe neuromuscular disease. 
    2. The seat lift mechanism must be a part of the treating practitioner?s course of treatment and be prescribed 
to effect improvement, or arrest or retard deterioration in the beneficiary's condition. 
    3. The beneficiary must be completely incapable of standing up from a regular armchair or any chair in their 
home. (The fact that a beneficiary has difficulty or is even incapable of getting up from a chair, particularly a 
low chair, is not sufficient justification for a seat lift mechanism. Almost all beneficiaries who are capable of 
ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) 
    4. Once standing, the beneficiary must have the ability to ambulate. 
 
Coverage of seat lift mechanisms is limited to those types which operate smoothly, can be controlled by the 
beneficiary, and effectively assist a beneficiary in standing up and sitting down without other assistance. 
Excluded from coverage is the type of lift which operates by spring release mechanism with a sudden, catapult-
like motion and jolts the beneficiary from a seated to a standing position. 
 
The practitioner ordering the seat lift mechanism must be the treating practitioner or a consulting practitioner 
for the disease or condition resulting in the need for a seat lift. The practitioner's record must document that all 
appropriate therapeutic modalities (e.g., medication, physical therapy) have been tried and failed to enable the 
beneficiary to transfer from a chair to a standing position. 
 
A seat lift mechanism that is electrically operated is billed using HCPCS code E0627. 
 
A manually operated seat lift mechanism is billed using HCPCS code E0629. 
 
When providing a seat lift mechanism that is incorporated into a chair as a complete unit at the time of 
purchase, suppliers must bill the item using the established HCPCS code for the seat-lift mechanism. In this 
situation, the supplier may bill the seat lift mechanism using E0627 or E0629, and bill A9270 for the chair. 
 
You can find this information in the Medicare Local Coverage Determination (LCD): Seat Lift Mechanisms 
(L33801) and Local Coverage Article: Seat Lift Mechanisms - Policy Article (A5251). 
 
 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.