Wheelchair Cushions & Backs

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Seat Lift

ICD-9 Diagnosis Codes

Qualification is contingent on a patient qualifying for a power or manual wheelchair with a sling/solid seat/back. Consult your DME MAC medical policy for a complete list of coverage criteria.

For HCPCS codes E2601, E2602 (Simplicity & TRU-Comfort):

There are no qualifying diagnosis codes for HCPCS codes E2601 & E2602.

For HCPCS codes E2603, E2604 (Solution 1, TRU-Comfort Plus), K0734, K0735 (Structure 2), either

1) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface:

707.03 DECUBITUS ULCER, LOWER BACK

707.04 DECUBITUS ULCER, HIP

707.05 DECUBITUS ULCER, BUTTOCK

Or 2) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9 LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0 ALZHEIMER’S DISEASE

332.0 PARALYSIS AGITANS

335.0 - 335.21 WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9 PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3 SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340 MULTIPLE SCLEROSIS

341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1 QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

741.00 - 741.93 SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

For HCPCS codes E2605, E2606 (Spectrum Gel), significant postural asymmetries due to one of the following:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9 LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0 ALZHEIMER’S DISEASE

332.0 PARALYSIS AGITANS

333.4 HUNTINGTON’S CHOREA

333.6 GENETIC TORSION DYSTONIA

333.71 ATHETOID CEREBRAL PALSY

334.0 - 334.9 FRIEDREICH’S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

335.0 - 335.21 WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9 PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3 SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340 MULTIPLE SCLEROSIS

341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

342.00 - 342.92 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING

NONDOMINANT SIDE

343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1 QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.40 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

741.00 - 741.93 SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

For HCPCS codes E2607, E2608 (Solution & Spectrum Foam), either

1) Significant postural asymmetries AND absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift due to one of the following:

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

330.0 - 330.9 LEUKODYSTROPHY - UNSPECIFIED CEREBRAL DEGENERATION IN CHILDHOOD

331.0 ALZHEIMER’S DISEASE

332.0 PARALYSIS AGITANS

335.0 - 335.21 WERDNIG-HOFFMANN DISEASE - PROGRESSIVE MUSCULAR ATROPHY

335.23 - 335.9 PSEUDOBULBAR PALSY - ANTERIOR HORN CELL DISEASE UNSPECIFIED

336.0 - 336.3 SYRINGOMYELIA AND SYRINGOBULBIA - MYELOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE

340 MULTIPLE SCLEROSIS

341.0 - 341.9 NEUROMYELITIS OPTICA - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED

343.0 - 343.9 CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED

344.00 - 344.1 QUADRIPLEGIA UNSPECIFIED - PARAPLEGIA

741.00 - 741.93 SPINA BIFIDA UNSPECIFIED REGION WITH HYDROCEPHALUS - SPINA BIFIDA LUMBAR REGION WITHOUT HYDROCEPHALUS

Or 2) Current pressure ulcer (707.03, 707.04, 707.05) or past history of a pressure ulcer (707.03, 707.04, 707.05) on the area of contact with the seating surface AND significant postural asymmetries due to one of the

following:

333.4 HUNTINGTON’S CHOREA

333.6 GENETIC TORSION DYSTONIA

333.71 ATHETOID CEREBRAL PALSY

334.0 - 334.9 FRIEDREICH’S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED

342.00 - 342.92 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING

NONDOMINANT SIDE

344.30 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

359.0 CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1 HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

438.20 - 438.22 HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.40 - 438.42 MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE CONTACT THE PRODUCT PLANNING & REIMBURSEMENT CENTER AT 1-800-800-8586 FOR MORE INFORMATION.

The information contained herein is correct at the time of publication; we reserve the right to alter specifications without prior notice

 

 

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