Tables and Boards

Number: 0481

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 tables and boards.

1. Medical Necessity

   Aetna considers rental, or if less costly, purchase, of the following tables and boards medically necessary durable medical equipment (DME) for the indications specified below:

   1. Postural drainage boards - for members with chronic pulmonary conditions;
   2. Prone boards (e.g., Prone Board Standing System, Rifton Supine Board) - for members with neuromuscular conditions such as cerebral palsy or quadriplegia, who need a prone board to assist them in being placed in an upright position;
   3. Stand Aid/Stand Alone - to improve lower body strength for members with paraplegia and other neuromuscular conditions who are unable to rise from a seated to standing position without assistance and have some residual strength in the hips or legs such that that they can maintain the standing position. Stand Aids/Stand Alone are not considered medically necessary for members with complete paralysis of the hips and legs, such that lower body strength is not improved by maintaining the standing position. For these latter members, the Stand Aid/Stand Alone has not been proven to offer clinically significant benefits because of insufficient evidence in the peer-reviewed literature.
   4. Standers, standard nonpowered - for members with spastic quadriplegia and other neuromuscular conditions who have impaired ability to stand, but once standing can maintain this position due to residual strength in the hips, legs and lower body. Standers provide limited assistance to permit the member to rise to a standing position, allowing the member to increase or maintain lower body strength by achieving the standing position. Standers have no proven value for persons with complete paralysis of the hips and legs, such that lower body strength is not improved by maintaining the standing position or for members unable to maintain the standing position. For these members, standers are not considered to offer clinically significant benefits because of insufficient evidence in the peer-reviewed literature. Standers have no proven value for the prevention or treatment of contractures.
   5. Tilt tables - for reconditioning of persons with orthostatic hypotension, such as due to stroke, spinal cord injury, prolonged immobilization, or advanced age;
   6. Transfer board - for members with medical conditions that limit their ability to transfer from wheelchair to bed, chair, toilet, etc.

2. Policy Limitations and Exclusions 

   Aetna does not cover the following tables and boards because they do not meet Aetna’s contractual definition of covered DME in that they are not primarily medical in nature, are normally of use to persons who do not have a disease or injury, and/or are not mainly used in the treatment of disease or injury: 

   1. Bed boards (board inserted between bed spring and mattress to give extra support);
   2. Cutout tables (table cutout for use with wheelchair or prone board);
   3. Foot boards (board at the end of the bed);
   4. Lapboards (board used on the lap as a table or desk);
   5. Over-the-bed tables (overbed tables) (e.g., Able Table);
   6. Standing tables (table for use in a standing position).

   Aetna considers the following tables and boards institutional equipment and not appropriate for home use: 

   1. Performa Power Mat Platform;
   2. Transfer discs (rotating foot disc used to assist staff in pivoting members who are difficult to transfer).

   Most Aetna benefit plans exclude coverage of exercise equipment. Please check benefit plan descriptions. Aetna considers the following tables and boards non-covered exercise equipment:

   1. Foot inversion boards (used to strengthen muscles below the knee);
   2. Stimulation boards (padded platform that rocks and is equipped with a safety belt; used for exercise).

3. Related Policies

   • CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters)

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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 covered if selection criteria are met:
E0606	Postural drainage board
E0637	Combination sit to stand system, any size including pediatric, with seat lift feature, with or without wheels
E0638	Standing frame system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels
E0641	Standing frame system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels
E0642	Standing frame system, mobile (dynamic stander), any size including pediatric
E0705	Transfer device, any type, each
HCPCS codes not covered for indications listed in the CPB:
A9300	Exercise equipment
E0274	Over-bed table
E0315	Bed accessory: board, table, or support device, any type
ICD-10 codes covered if selection criteria are met:
G70.00 - G70.9	Myasthenia gravis and other myoneural disorders
G73.3	Myasthenic syndromes in diseases classified elsewhere
G80.0 - G80.9	Cerebral palsy
G82.20 - G82.54	Paraplegia (paraparesis) and quadriplegia (quadriparesis)
I69.098, I69.198 I69.298, I69.398 I69.898, I69.998	Other sequelae of cerebrovascular disease
I95.1	Orthostatic hypotension
J40 - J47.9 J67.0 - J67.9	Chronic lower respiratory diseases and other lung diseases due to external agents
S14.0xxS - S14.159S S24.101S - S24.159S S34.01xS - S34.139S	Injury of nerves and spinal cord, sequela
ICD-10 codes not covered for indications listed in the CPB (for standers):
M24.50 - M24.9	Contracture of joint
M62.40 - M62.49 M62.830 - M62.838	Contracture of muscle [spasm]

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Background

A tilt table is a table that tilts from a nearly horizontal to a vertical position.  It is primarily used for re-conditioning of persons with orthostatic hypotension, such as due to stroke, spinal cord injury, prolonged immobilization, or advanced age.  The patients are re-conditioned to standing by gradually increasing the duration of tilting and the angle of inclination from day to day.  There is significant risk of loss of consciousness if the angle of inclination or the duration of use is too great.  Tilt tables are generally used in a facility setting and by physical therapists, but some tables are made for home use.  For use of a tilt table at home, arrangements should be made to have an appropriate attendant (e.g., nurse, home health aide, trained family member) to supervise its use.

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References