Canes and Crutches - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**

For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed
body member, and 3) meet all other applicable Medicare statutory and
regulatory requirements. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").

Canes and Crutches are covered under the Durable Medical Equipment benefit
(Social Security Act 1861(s)(6)). In order for a beneficiary's equipment to
be eligible for reimbursement the reasonable and necessary (R&N) requirements
set out in the related Local Coverage Determination must be met. In addition,
there are specific statutory payment policy requirements, discussed below,
that also must be met.

A white cane for a blind person is noncovered since it is more of an
identifying and self-help device than an item which makes a meaningful
contribution in the treatment of an illness or injury (see CMS _National
Coverage Determinations Manual_ (CMS Pub. 100-03), Chapter 1, Part 4, Section
280.2).

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)**

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).  

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD prior to delivery,
it will be eligible for coverage.

**POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**

In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.

Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS.

**CODING GUIDELINES**

Code A9270 must be used for a white cane for a blind person.

All canes and crutches are billed using the specific codes listed in the Local
Coverage Determination regardless of their stated weight capacity. Do not use
code E1399 (DME, miscellaneous) to code any type of cane or crutch regardless
of special features or weight capacity.

Code E0117 describes an articulating crutch which has two crutch legs
connected by a bar between them which helps propel the beneficiary forward.

Code E0118 describes a crutch substitute which can be either a device strapped
to the lower leg with a platform or a device with wheels and a platform the
beneficiary propels with their sound limb.

Canes or crutches which contain a spring that reduces impact and vibration
against the ground should not be billed with E1399. These types of canes or
crutches should be coded with the existing codes for canes or crutches.

Suppliers should contact the Pricing, Data Analysis and Coding (PDAC)
Contractor for guidance on the correct coding of these items.