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 commode is covered when the beneficiary is physically incapable of utilizing
regular toilet facilities. This would occur in the following situations:

  1. The beneficiary is confined to a single room, or

  2. The beneficiary is confined to one level of the home environment and there is no toilet on that level, or

  3. The beneficiary is confined to the home and there are no toilet facilities in the home.

An extra wide/heavy duty commode chair (E0168) is covered for a beneficiary
who weighs 300 pounds or more. If an E0168 commode is ordered and the
beneficiary does not weigh more than 300 pounds, it will be denied as not
reasonable and necessary.

A commode chair with detachable arms (E0165) is covered if the detachable arms
feature is necessary to facilitate transferring the beneficiary or if the
beneficiary has a body configuration that requires extra width. If coverage
criteria are not met payment will be denied as not reasonable and necessary.

Commode chair with seat lift mechanism (E0170, E0171) is covered if the
beneficiary has medical necessity for a commode and meets the coverage
criteria for a seat lift mechanism (see Local Coverage Determination (LCD) and
Policy Article on Seat Lift Mechanisms). However, a commode with seat lift
mechanism is intended to allow the beneficiary to walk after standing. If the
beneficiary can ambulate, he/she would rarely meet the coverage criterion for
a commode. Therefore, if the beneficiary is capable of walking from the bed to
the bathroom, a KX modifier must not be added to the code for the commode with
seat lift mechanism.

Bidets and bidet toilet seats are non-covered (no benefit - see related Policy
Article).  
  
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.