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 a custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom 
fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 
 
    Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
 
    Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
 
    There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical 
therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not 
sufficient to meet the beneficiarys seating and positioning needs. The PT or OT may have no financial 
relationship with the supplier. 
 
If a custom fabricated cushion is provided for a beneficiary who does not meet the stated coverage criteria, it 
will be denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination 
(LCD) Wheelchair Seating L33312. 
 
The rules that for a custom fabricated seat or back cushion (E2609, E2617), a KX modifier must be added to 
the code only if criterion (a) is met and criterion (b), (c), or (d) is met: 
 
    For E2609 or E2617, there is a comprehensive written evaluation by a licensed/certified medical 
professional, such as a PT or OT (who has no financial relationship with the supplier) which explains why a 
prefabricated seating system is not sufficient to meet the beneficiarys seating and positioning needs; and 
 
    For E2609, there is a past history of, or current, pressure ulcer in the area of contact with the seating surface; 
or 
 
    For E2609, there is absent or impaired sensation in the area of contact with the seating surface or an inability 
to carry out a functional weight shift due to one of the diagnoses listed as a covered diagnosis for skin 
protection cushions (refer to the ICD-10 code list section); or 
 
    For E2609 or E2617, the beneficiary has significant postural asymmetries due to one of the diagnoses listed 
as a covered diagnosis for positioning cushions (refer to the ICD-10 code list section). A custom fabricated seat cushion (E2609) and a custom fabricated back cushion (E2617) are cushions that are 
individually made for a specific beneficiary starting with basic materials including: 
 
    liquid foam or a block of foam and 
 
    sheets of fabric or liquid coating material. 
 
The cushion must be fabricated using one or more of the following techniques to capture the individual shape 
of the beneficiary: 
 
    molded-to-beneficiary-model technique; 
    direct molded-to-beneficiary technique; 
    CAD/CAM technology, which: 
        allows for the use of direct digital scanning of the beneficiary or of a mold made directly from the 
beneficiary; 
        allows for direct milling of either (1) a beneficiary-specific model used to shape the cushion contour or (2) 
the cushion contours; or 
    detailed measurements of the beneficiary used to create a configured cushion. 
 
The cushion must have structural features that significantly exceed the minimum requirements for a seat or 
back positioning cushion. The cushion must have a removable vapor permeable or waterproof cover, or it must 
have a waterproof surface. A custom fabricated cushion may include certain prefabricated components (e.g., 
gel or multi-cellular air inserts); these components must not be billed separately. If a custom fabricated seat and 
back are integrated into a one-piece cushion, code as E2609 plus E2617. You can find these rules in the Local 
Coverage Article Wheelchair Seating - Policy Article A52505. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.