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 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.

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.

Per the 2022 Medicare Fee-for Service Supplemental Improper Payment Data, the
overall CERT error rate for DMEPOS claims is 25.2%. Claims for items which
have recently had Certificates of Medical Necessity (CMNs) or Durable Medical
Equipment Information Forms (DIFs) eliminated represent an area of potential
vulnerability that may increase the CERT error rate.

As outlined in the CMS _Program Integrity Manual_ (Pub. 100-08) Chapter 1,
Section 1.3.8, the DME MACs are responsible for reducing the payment error
rate by preventing initial payment of claims that do not comply with
Medicare's coverage, coding, payment, and billing policies. The DME MACs are
continually looking to identify any potential vulnerabilities that may
increase the CERT error rate and have recognized that claims for items which
have recently had the CMNs or DIFs eliminated may represent one such
vulnerability. Therefore, the DME MACs are proposing the addition of the KX,
GA and GZ modifiers to properly indicate when claims for seat lift mechanisms
re reasonable and necessary.