Bathroom and Toilet Equipment and Supplies

Number: 0429

Table Of Contents

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

---

Policy

Scope of Policy

This Clinical Policy Bulletin addresses bathroom and toilet equipment and supplies.

1. Medical Necessity

   Aetna considers the following bathroom and toilet equipment and supplies as medically necessary durable medical equipment (DME) items when applicable criteria are met. For plan-specific information (i.e., Aetna HMO-based plans and traditional plans), see section III.

   1. Commode chair

      A commode chair (stationary or mobile) is considered medically necessary for members who are physically incapable of using regular toilet facilities. This would also occur in the following situations:

      1. The member is confined to a single room, or  
      2. The member is confined to 1 level of the home environment and there is no toilet on that level, or
      3. The member is confined to the home and there are no toilet facilities in the home.  

   2. Commode chair with detachable arms

      A commode chair with detachable arms is considered medically necessary DME when member meets criteria for a commode chair (above) and the detachable arms feature is necessary to facilitate transferring the member or member has a body configuration that requires extra width.

   3. Commode chair with seat lift mechanism

      A commode chair with integrated seat lift mechanism is considered medically necessary DME when member meets both medical necessity criteria for a commode chair (above) and medical necessity criteria for a seat lift in CPB 0459 - Seat Lifts and Patient Lifts. However, a commode with seat lift mechanism is intended to allow a person to walk after standing. If the member can ambulate, he/she would rarely meet the medical necessity criterion for a commode.

   4. Rehab shower commode chair

      1. Rehab shower commode chair

         Rehab shower commode chair is a considered medically necessary DME for members 12 months of age or older who require complex positioning during bathing and toileting, and where the bathroom allows practical use of a combined shower commode device, and when all of the following criteria are met:

         1. Member has a documented medical condition which results in the need for supportive seating to enable safe and effective bathing, such as (not an all-inclusive list):

            1. a neurological disease (e.g.,  amyotrophic lateral sclerosis (ALS), cerebral palsy, multiple sclerosis, muscular dystrophy, paraplegia, spinal cord injury causing neurologic deficits)
            2. an orthopedic condition (e.g., lower extremity amputation); and
         2. Member is unable to stand for the duration of a shower or enter/exit the bathtub, needs support while sitting, or needs support for toileting; and
         3. Member was seen for a face-to-face examination by their treating physician within 6 months of the Standard Written Order (SWO) documenting medical necessity; and
         4. Member was seen for a specialty evaluation by an Occupational and/or Physical Therapist to determine the type of device that meets the member’s medical needs, is efficacious and safe for the member’s use, including during transfers on and off the device; and
         5. A home assessment was completed by the Assistive Technology Professional (ATP) with written documentation that the home is accessible for the requested rehab shower commode chair; and
         6. Member had a successful trial of the requested device and documentation to support that a lower cost system will not meet the needs of the individual;

      2. Seating and positioning components and accessories for rehab shower commode

         The following items are are considered medically necessary when criteria are met and the clinical documentation provided includes medical justification for the item:

         1. Other accessories, including but not limited to, bath chair lateral supports, chest or pelvic straps, wedge, headrest, and/or pommel, cushions when member requires additional support to maintain head, lateral thigh, knee, lateral trunk in proper alignment or to maintain the member safely on the bath chair while bathing;
         2. A tilt/recline rehab shower commode chair when member meets all the criteria for a rehab shower commode chair (above) and meets one of the following criteria:
            
            
            1. Member has extensive weakness, contractures, or abnormal tone requiring full body support; or
            2. Member requires total assistance for transfers and bathing; or
            3. Member has a medical need that requires the tilted or reclined position when upright; or
            4. Member requires pressure relief at all times when sitting (such as for prevention or treatment of pressure sores);

         3. Elevating leg rests when the member meets the criteria for a rehab shower commode chair (above) and meets one of the following criteria:

            1. Member has a musculoskeletal condition which prevents 90-degree flexion of the knee; or
            2. Member meets medical necessity for the tilt/recline feature on the rehab shower commode chair;
         4. Extra wide/heavy duty devices may be appropriate for members who meet the above criteria and weigh more than 300 pounds;
         5. Rehab shower commode chair accessories and positioning components must contribute to the therapeutic function of the chair. Accessories primary for caregiver convenience are considered not medically necessary;

      3. Replacement criteria

         Replacement of any rehab shower commode chair must meet all relevant criteria for medical necessity (see above) and meets one or more of the following:

         1. When member has outgrown the device; or
         2. When the device no longer meets the needs of the member; or
         3. The device is no longer functional through normal wear and tear (expected to last at least 5 years) and replacement is not the result of misuse or abuse;

      4. Repair criteria

         Repairs or replacement of worn, torn, or broken existing parts or accessories are considered medically necessary when needed to make the rehab shower commode chair serviceable and operational. Repair is considered only for client-owned equipment 

         1. Repairs for authorized rehab shower commode chair is considered medically necessary when all of the following are met:

            1. Aetna originally authorized and purchased the rehab shower commode chair and accessories, or the supplier provides clinical documentation for Aetna to establish medical necessity for the member's rehab shower commode chair previously authorized by another health plan; and
            2. Repairs are not the result of misuse or abuse; and
            3. Repair cost is less than replacement;

         2. Documentation requirements

            1. Age, make and model, date and who purchased the rehab shower commode chair being repaired, cost of repairs versus replacement (if applicable)
            2. List of all accessories or part including description of repair and explanation/justification.

   5. Note: One piece of equipment is considered medically necessary when criteria are met (above); however, second items are considered a convenience item.

2. Not Medically Necessary

   Aetna considers any device that requires a home modification as not not medically necessary.

3. Plan-Specific Information

   1. Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom.  Most DME items used in the bathroom are considered by Medicare to be personal convenience items.  Consistent with Medicare rules, Aetna's HMO-based plans, however, do consider certain DME toilet items (commodes, bed pans, etc.) medically necessary if the member is bed-confined or room-confined.
   2. Aetna's traditional plans (indemnity, PPO, and Managed Choice POS) typically consider DME used in the bathroom medically necessary if the DME is primarily medical in nature, not normally of use in the absence of illness and injury, and if it is necessary for daily activities related to health and personal hygiene.  Bathing and toileting are among the activities of daily living that are considered essential to health and personal hygiene. 

   The following lists bathroom items and whether they are covered DME under Aetna HMO and traditional plans.  For covered items, medical necessity criteria are set forth in the footnotes.

   Table: Bathroom Items and Covered Plans

   Bathroom Item	HMO-based	Traditional
   Bath cast protector	No	No
   Bath mats	No	No
   Bathtub safety frame	No	YesFootnote11
   Bathtub lifts (bath chair lift)	No	YesFootnote11
   Bathtub seats (bath bench, tub chair)	No	YesFootnote22
   Bathtub transfer board	No	YesFootnote11
   Bed baths (home type)	No	YesFootnote33
   Bed pans (autoclavable hospital type)	YesFootnote33	YesFootnote33
   Bidet toilet seat	No	No
   Commodes	YesFootnote44	YesFootnote44
   Commode chair as raised toilet seat	NoFootnote55	YesFootnote55
   Foot baths	No	No
   Grab bars (affixed to wall)	No	No
   Hand-held shower	No	No
   Raised toilet seats	No	YesFootnote66
   Rehab shower chair / commode	No	Yes
   Sauna baths	No	No
   Shampoo tray	No	No
   Shower bench (shower chair)	No	YesFootnote22
   Shower massage	No	No
   Sitz bath	YesFootnote77	YesFootnote77
   Toilet safety frame	No	YesFootnote11
   Toilet seat lift (erector)	No	YesFootnote66
   Toilet trainer	No	No
   Urinals (autoclavable hospital type)	YesFootnote33	YesFootnote33
   Weight scales	No	No
   Whirlpools and pumps (portable and nonportable) (e.g., Jacuzzi, Hydro-jet, Turbo-jet)	No	No

   Key: Yes – considered medically necessary; No – considered non-covered personal convenience item.

   Medical Necessity Criteria

   Footnote1¹ Considered medically necessary if member is unable to transfer to and from tub

   Footnote2² Considered medically necessary if member is unable to bathe or shower without being seated

   Footnote3³ Considered medically necessary if member is bed-confined or room-confinedFootnote8*

   Footnote4⁴ Considered medically necessary according to selection criteria set forth in section on commodes.

   Footnote5⁵ Considered medically necessary for members who are unable to rise from a toilet seat without assistance. Note: Aetna's HMO and health network based plans follow Medicare rules for commode chairs.  Medicare considers raised toilet seats personal convenience items. Therefore, Aetna's HMO and health network-based plans consider a commode chair a non-covered personal convenience item if the commode chair is to be used as a raised toilet seat by positioning it over the toilet.

   Footnote6⁶ Considered medically necessary if member is unable to rise from toilet seat without assistance.

   Footnote7⁷ Considered medically necessary for infection or injury of the perineal area

   Footnote8* Note: For this policy, the term "room-confined" means that the member’s condition is such that leaving the room is medically contraindicated.  The accessibility of bathroom facilities generally would not be a factor in this determination.  However, confinement of a member to his home in a case where there are no toilet facilities in the home may be equated to room confinement.  In addition, a member may be considered “room-confined” if a member’s medical condition confines her/him to a floor of their home and there is no bathroom located on that floor.

4. Other

   Note: For use of an unlisted code: documentation should establish that the member meets the medical necessity criteria (above) and includes the name of the item, description, the manufacturer, product number, with the letter of medical necessity including both of the following:

   1. A description of the features of the E1399 equipment not available with standard equipment and accessories (E0240 for any size bath/shower chair, whether it has wheels or not; E0245 (tub stool or bench), E0246 (transfer tub rail attachment), and E0247/E0248 (transfer benches)); and
   2. A description of the functional limitations and underlying medical condition of the member which require the use of those features.

---

Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
HCPCS codes covered if selection criteria are met:
E0160	Sitz type bath or equipment, portable, used with or without commode
E0161	Sitz type bath or equipment, portable, used with or without commode, with faucet attachment(s)
E0162	Sitz bath chair
E0163	Commode chair, mobile or stationary, with fixed arms
E0165	Commode chair, mobile or stationary, with detachable arms
E0167	Pail or pan for use with commode chair, replacement only
E0168	Commode chair, extra wide and/or heavy duty, stationary or mobile, with or without arms, any type, each
E0170	Commode chair with integrated seat lift mechanism, electric, any type
E0171	Commode chair with integrated seat lift mechanism, non-electric, any type
E0172	Seat lift mechanism placed over or on top of toilet, any type
E0175	Footrest, for use with commode chair, each
E0240 (for Traditional plans)	Bath/shower chair, with or without wheels, any size
E0244 (for Traditional plans)	Raised toilet seat
E0245 (for Traditional plans)	Tub stool or bench
E0247 (for Traditional plans)	Transfer bench for tub or toilet with or without commode opening
E0248 (for Traditional plans)	Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0275	Bed pan, standard, metal or plastic
E0276	Bed pan, fracture, metal or plastic
E0325	Urinal; male, jug-type, any material
E0326	Urinal; female, jug-type, any material
E0625 (for Traditional plans)	Patient lift, bathroom or toilet, not otherwise classified
E0627 (for Traditional plans)	Seat lift mechanism, electric, any type
E0629 (for Traditional plans)	Seat lift mechanism, non-electric, any type
E0705	Transfer device, any type, each
E0968	Commode seat, wheelchair
HCPCS codes not covered for indications listed in the CPB:
E0170 (for HMO-based)	Commode chair with integrated seat lift mechanism, electric, any type
E0171 (for HMO-based)	Commode chair with integrated seat lift mechanism, non-electric, any type
E0172 (for HMO-based)	Seat lift mechanism placed over or on top of toilet, any type
E0240 (for HMO-based plans)	Bath/shower chair, with or without wheels, any size
E0241	Bathtub wall rail, each
E0242	Bathtub rail, floor base
E0243	Toilet rail, each
E0244 (for HMO-based plans)	Raised toilet seat
E0245 (for HMO-based plans)	Tub stool or bench
E0246	Transfer tub rail attachment
E0247 (for HMO-based plans)	Transfer bench for tub or toilet with or without commode opening
E0248 (for HMO-based plans)	Transfer bench, heavy duty, for tub or toilet with or without commode opening
E0249	Pad for water circulating heat unit
E0625 (for HMO-based plans)	Patient lift, bathroom or toilet, not otherwise classified
E0627 (for HMO-based plans)	Seat lift mechanism, electric, any type
E0629 (for HMO-based plans)	Seat lift mechanism, non-electric, any type
E1300	Whirlpool, portable (overtub type)
E1301	Whirlpool tub, walk-in, portable
E1310	Whirlpool, nonportable (built-in type)
HCPCS codes covered if selection criteria are met [for traditional plan]:
Rehab shower commode chair, accessories for rehab shower commode, tilt/recline rehab shower commode chair, elevating leg rests for rehab shower commode - no specific code
HCPCS codes not covered for indications listed in the CPB [for HMO plan]:
Rehab shower commode chair, accessories for rehab shower commode, tilt/recline rehab shower commode chair, elevating leg rests for rehab shower commode - no specific code
ICD-10 codes covered if selection criteria are met:
A52.17	General paresis [covered for tilt/recline rehab shower commode chair]
G04.1	Tropical spastic paraplegia
G11.4	Hereditary spastic paraplegia
G12.21	Amyotrophic lateral sclerosis
G35	Multiple sclerosis
G71.00-G71.11	Muscular dystrophy
G80.0-G80.9	Cerebral Palsy
G81.10-G81.14	Spastic hemiplegia
G82.20-G82.22	Paraplegia
G82.50-G82.54	Quadriplegia
G83.0-G83.34	Other paralytic syndromes
G83.81-G83.89	Other specified paralytic syndromes
G83.9	Paralytic syndrome, unspecified
L89.0-L89.96	Pressure ulcer [covered for tilt/recline rehab shower commode chair]
M24.50-M24.59	Contracture of joint [covered for tilt/recline rehab shower commode chair]
M62.40-M62.49	Contracture of muscle [covered for tilt/recline rehab shower commode chair]
M62.81	Muscle weakness (generalized) [covered for tilt/recline rehab shower commode chair]
P11.5	Birth injury to spine and spinal cord
R53.1	Weakness [covered for tilt/recline rehab shower commode chair]
S14.0XXA-S34.139S	Spinal cord injury
S34.21XA-S34.9XXS	Injury of nerves and spinal cord
S78.011A-S78.929S	Traumatic amputation of hip and thigh
S88.011A-S88.929S	Traumatic amputation of lower leg
S98.011A-S98.929S	Traumatic amputation of ankle and foot
Z89.41-Z89.449	Acquired absence of toe(s), foot, and ankle
Z89.51-Z89.529	Acquired absence of leg below knee
Z89.61-Z89.629	Acquired absence of leg above knee
Z89.9	Acquired absence of limb, unspecified

---

Background

An extra wide/heavy commode chair is defined as one that has a width of greater than or equal to 23 inches and is capable of supporting a person who weighs 300 pounds or more.

A raised toilet seat is a device that adds height to the toilet seat.  It is either fixed height or adjustable.  It is either attached to the toilet or is unattached, resting on the bowl.  (Note: A free-standing raised toilet seat supported by legs on the floor is considered a commode.)

A toilet seat lift mechanism is a device with a seat that can be raised with or without a forward tilt while the patient is seated, allowing the patient to stand and ambulate once he/she is in an upright position.  It may be manually operated or electric.  It is attached to the toilet.

A commode with seat lift mechanism is a free-standing device that has a commode pan and that has an integrated seat that can be raised with or without a forward tilt while the patient is seated.  An integrated device is one which is sold as a unit by the manufacturer and in which the lift and the commode can not be separated without the use of tools.

---

References