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.  
  
The purpose of a Local Coverage Determination (LCD) is to provide information
regarding "reasonable and necessary" criteria based on Social Security Act 
1862(a)(1)(A) provisions.  
  
In addition to the "reasonable and necessary" criteria contained in this LCD
there are other payment rules, which are discussed in the following documents,
that must also be met prior to Medicare reimbursement:

  * The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  * The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

  * Refer to the Supplier Manual for additional information on documentation requirements.

  * Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the "reasonable and necessary" criteria,
based on Social Security Act  1862(a)(1)(A) provisions, are defined by the
following coverage indications, limitations and/or medical necessity.  
  
A general use seat cushion (E2601, E2602) and a general use wheelchair back
cushion (E2611, E2612) are covered for a beneficiary who has a manual
wheelchair or a power wheelchair with a sling/solid seat/back which meets
Medicare coverage criteria. If the beneficiary does not have a covered
wheelchair, then the cushion will be denied as not reasonable and necessary.
If the beneficiary has a POV or a power wheelchair with a captain's chair
seat, the cushion will be denied as not reasonable and necessary.  
  
For beneficiaries who meet coverage criteria for a power wheelchair and who do
not have special skin protection or positioning needs, a power wheelchair with
Captain's Chair provides appropriate support. Therefore, if a general use
cushion is provided with a power wheelchair with a sling/solid seat/back
instead of Captain's Chair, the wheelchair and the cushion(s) will be covered
if either criterion 1 or criterion 2 is met:

  1. The cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model - i.e., codes K0839, K0840, K0843, K0860, K0861, K0862, K0863, K0864, K0890, K0891; or

  2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.

If one of these criteria is not met, both the power wheelchair with a
sling/solid seat and the general use cushion will be denied as not reasonable
and necessary.  
  
If the beneficiary has a POV or a power wheelchair with a captain's chair
seat, a separate seat and/or back cushion will be denied as not reasonable and
necessary.  
  
A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a
beneficiary who meets both of the following criteria:

  1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and

  2. The beneficiary has either of the following (a or b):

    1. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or

    2. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article.

A positioning seat cushion (E2605, E2606), positioning back cushion (E2613,
E2614, E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955,
E0956, E0957, E0960) are covered for a beneficiary who meets both of the
following criteria:

  1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and

  2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b):

    1. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or

    2. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article.

A combination skin protection and positioning seat cushion (E2607, E2608,
E2624, E2625) is covered for a beneficiary who meets the criteria for both a
skin protection seat cushion and a positioning seat cushion. (Note special
instructions for a combination skin protection and positioning cushion in the
ICD-10 code list in the LCD-related Policy Article.)  
  
A headrest (E0955) is also covered when the beneficiary has a covered manual
tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a
manual fully reclining back on a power wheelchair, or power tilt and/or
recline power seating system.  
  
If the beneficiary has a POV or a power wheelchair with a captain's chair
seat, a headrest or other positioning accessory will be denied as not
reasonable and necessary.  
  
If a skin protection seat cushion, positioning seat cushion, or combination
skin protection and positioning seat cushion is provided and if the stated
coverage criteria are not met, it will be denied as not reasonable and
necessary.  
  
If a positioning back cushion is provided for a beneficiary who does not meet
the stated coverage criteria, it will be denied as not reasonable and
necessary.  
  
If a positioning accessory is provided and the criteria are not met, the item
will be denied as not reasonable and necessary.  
  
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:

  1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;

  2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion;

  3. 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 beneficiary's 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.  
  
A seat or back cushion that is provided for use with a transport chair (E1037,
E1038) will be denied as not reasonable and necessary.  
  
The effectiveness of a powered seat cushion (E2610) has not been established.
Claims for a powered seat cushion will be denied as not reasonable and
necessary.  
  
A prefabricated seat cushion, a prefabricated positioning back cushion, or a
brand name custom fabricated seat or back cushion which has not received a
written coding verification from the Pricing, Data Analysis, and Coding (PDAC)
contractor or which does not meet the criteria stated in the Coding Guidelines
section (see Policy Article) will be denied as not reasonable and necessary.  
  
GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a
claim is submitted. If the supplier bills for an item addressed in this policy
without first receiving a completed SWO, the claim shall be denied as not
reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
base items that require a Written Order Prior to Delivery (WOPD), the supplier
must have received a signed SWO before the DMEPOS item is delivered to a
beneficiary. If a supplier delivers a DMEPOS item without first receiving a
WOPD, the claim shall be denied as not reasonable and necessary. Refer to the
LCD-related Policy Article, located at the bottom of this policy under the
Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed
associated options, accessories, and/or supplies, the supplier must have
received a WOPD which lists the base item and which may list all the
associated options, accessories, and/or supplies that are separately billed
prior to the delivery of the items. In this scenario, if the supplier
separately bills for associated options, accessories, and/or supplies without
first receiving a completed and signed WOPD of the base item prior to
delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines
listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC
articles. Claims that do not meet coding guidelines shall be denied as not
reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are
required to maintain POD documentation in their files. Proof of delivery
documentation must be made available to the Medicare contractor upon request.
All services that do not have appropriate proof of delivery from the supplier
shall be denied as not reasonable and necessary.