Pillows and Cushions

Number: 0456

Table Of Contents

Policy
Applicable CPT / HCPCS / ICD-10 Codes
Background
References

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Policy

Scope of Policy

This Clinical Policy Bulletin addresses pillows and cushions.

1. Experimental and Investigational

   Aetna considers the MedCline Positioning Device experimental and investigational for gastroesophageal reflux disease and other indications.

2. Policy Limitations and Exclusions

   Aetna does not cover most therapeutic pillows and cushions because they do not meet Aetna's contractual definition of durable medical equipment (DME) in that they are not durable and because they are not primarily medical in nature and not mainly used in the treatment of disease or injury.

   Cushions may be covered if it is an integral part of, or a medically necessary accessory to, covered DME.  For example, see CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters) (wheelchair seat cushions are covered to prevent or treat severe burns or decubiti).

   Certain specialized support surfaces may be covered when medically necessary to prevent or treat decubitus ulcers.  For medical necessity criteria for specialized cushions to prevent decubiti, see CPB 0430 - Pressure Reducing Support Surfaces.
   
   

   The following are some types of pillows and cushions that are not covered by Aetna:

   • Backrest cushions and lumbar pillows including lumbar cushions, lumbar pads, lumbar rolls (e.g., Accu-Back Orthopedic Cushion, Back-Huggar, Better Back Support, ChiroFlow Adjustable Back Support, Comfort Core Backrest, Hibak Rest, Lumbo Cushion, Luniform, McCarty's Sacro-East Cushion, Sacro-Ease, Sitback Rest, Slimrest, SunMark Sacro Cushion)
   • Cervical pillows (cervical pillow rolls, neck cushions) (e.g., Hot 'n Cold Cervical Pillow, inflatable neck rest cushions, LuLu's Ortho Pillows, Nek-L-O Pillow, Orthopillow, Theracloud Cervical Smart Pillow, Therashield U-neck, Therapeutics, Wal-Pil-O, Wave Pillow, Youth Pillow)
   • Custom-molded cushions (e.g., Contour-U Customold Cushion)
   • Heat & Massage Foam Cushion Pad
   • Massage pillows (e.g., Niagara Massage Pillow)
   • Positioning pillows (e.g., Bed Wedge, Darbo Deluxe Knee Cushion, Knee Elevator, Leg Spacer, Posture Wedge Cushion, Soothe-A-Ciser, Stress Wedge, Ther-Arc, Tucker wedge/sling, etc.)
   • Sleeping pillows (ergonomic pillows, orthopedic pillows, orthopedic foam wedges) (e.g., Accu-Back Ergonomic Sleeping Pillow, Core Pillow, Mediflow Waterbase Pillow, MyPillow)
   • Specialized pillows for disabled children (e.g., Grasshopper Pillow, Tumble Form Pillow)
   • Standard pillows made of allergy-free materials
   • Traction pillows (e.g., Dutchman's roll, flexion pillow, pelvic sacral blocks, sternal roll, etc.)

3. Related Policies

   • For the Zzoma Positional Device to treat obstructive sleep apnea, see CPB 0004 - Obstructive Sleep Apnea in Adults.

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
HCPCS codes not covered for indications listed in the CPB:
MedCline Positioning Device, heat and massage foam cushion pad - no specific code:
E0190	Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories
Other HCPCS codes related to the CPB:
A7032	Cushion for use on nasal mask interface
A7033	Pillow for use on nasal cannula type interface, replacement only, pair
E1701	Replacement cushions for jaw motion rehabilitation system, package of six
E2601	General use wheelchair seat cushion, width less than 22 in., any depth
E2602	General use wheelchair seat cushion, width 22 in. or greater, any depth

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Background

A number or specialized pillows and cushions have been used for cushioning and positioning in the treatment of decubiti, burns, musculoskeletal injuries and other medical conditions.  Aetna does not generally cover pillows and cushions, regardless of medical necessity, because they do not meet Aetna's definition of covered durable medical equipment, in that pillows and cushions are not made to withstand prolonged use.  In addition, most pillows and cushions are not primarily medical in nature, and are normally of use to persons who do not have a disease or injury.

Person et al (2013) reported on an industry-sponsored single-institution, randomized controlled trial evaluating a sleep device (SD) to prevent gastroesophageal reflux disease, consisting of a 2-piece inclined base and body pillow (Medcline, Amenity Health, Inc., San Diego, CA) that maintains a patient in lateral position while elevating the head and torso.  The study involved 20 healthy volunteers, each subject having 4 impedance-pH tests 6 hours in length.  After placement of a reflux probe subjects returned home and ate a standardized meal (1,350 kcal, 58g fat).  Each subject then lay down in 1 of 4 randomly assigned positions:

1. SD right side down (SD-R),
2. SD left side down (SD-L),
3. standard wedge any position (W), and
4. flat any position (F). 

A wireless position monitor documented position during each study.  Number of reflux episodes (RE) and esophageal acid exposure (EAE) was blindly calculated for 6 hour periods.  Position monitor data were used to compare assigned position to actual position.  The investigators found significantly less esophageal acid exposure over 6 hrs occurred sleeping SD-L compared to sleeping W (mean 0.46 % versus 3.59 %, p < 0.01), SD-R (mean 0.46 % versus 4.59 %, p < 0.001), and F (mean 0.46 % verus 3.46 %, p < 0.05).  Reflux episodes over 6 hrs were significantly less SD-L than SD-R (mean 5.55 versus 13.23, p < 0.05).  Patients assigned to SD-L on average spent 83 % of first 2 hrs and 61 % of 6 hrs in assigned position.  Those assigned to SD-R spent 72 % of first 2 hrs and 53 % of 6 hrs in assigned position.  Over 6 hrs, patients sleeping on W and F averaged significantly more time supine than R or L (p < 0.05).  Limitations of the study included small sample size and use of healthy volunteers rathter than persons with gastro-esophageal reflux disease.  The authors stated that additional studies involving larger numbers of patients and longer durations of follow-up and clinical end-points are needed, as well as comparisons with positioning using non-medical pillows and bed elevation.

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References