Therapeutic Chairs

Number: 0434

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 therapeutic chairs.

1. Medical Necessity

   Aetna traditional plans consider the following postural support / therapeutic chairs and seating / positioning components and accessories medically necessary durable medical equipment (DME) (unless otherwise stated) when criteria are met:

   1. Postural Support / Therapeutic Chair

      To enable the member to perform essential activities of daily living related to the member's health and hygiene within the home when all of the following criteria are met:

      1. Member has postural instability or weakness and needs external supports to maintain position while seated; and
      2. Member was seen for a face-to-face or telehealth examination by their treating physician within 6 months of the Standard Written Order (SWO) documenting medical necessity; and
      3. Member was seen for a specialty evaluation by an occupational and/or physical therapist to determine 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
      4. A home assessment was completed by the Assistive Technology Professional (ATP) with written documentation that the home is accessible for the postural support/therapeutic chair; and
      5. Member had a successful trial of the requested device and there is documentation to support that a less costly system will not meet the needs of the individual;

      Notes:  

      If member has a wheelchair that provides postural support and positioning components, they are not a candidate for a postural/therapeutic chair, therefore would be considered a duplicate DME item (check plan specific language). 

      Postural support/therapeutic chair for alternative seating would be considered personal care, comfort, or convenience item.

      One piece of equipment is considered medically necessary when criteria are met (above); however, more than one item is considered a convenience item.

   2. Seating / Positioning Components and Accessories

      1. Including but not limited to, postural lateral supports, chest or pelvic straps, wedge, headrest, and/or pommel, cushions, trays) for the postural support/therapeutic chair when the member requires additional support to maintain head, trunk, and lower extremities in proper alignment or to keep member positioned safely;

         Postural support/therapeutic chair accessories and positioning components must contribute to the therapeutic function of the chair. Accessories primary for caregiver convenience are considered not medically necessary.

      2. Tilt / recline of the postural support/therapeutic chair when member meets all the criteria for a the postural support / therapeutic 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 has a medical need that requires the tilted or reclined position when upright; or
         3. Member requires pressure relief when sitting (such as for prevention or treatment of pressure sores);

   3. Replacement Criteria

      Replacement of any the postural support / therapeutic 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

      1. Repairs for authorized the postural support / therapeutic chair is considered medically necessary when all of the following are met:

         1. Aetna originally authorized and purchased the postural support/therapeutic chair and accessories, or the supplier provides clinical documentation for Aetna to establish medical necessity for the member's posture support 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 postural support / therapeutic chair being repaired, cost of repairs versus replacement (if applicable)
         2. List of all accessories or part including description of repair and explanation/justification.

2. 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; and
   2. A description of the functional limitations and underlying medical condition of the member which require the use of those features.

3. Plan Limitations and Exclusions

   Aetna HMO plans (HMO, QPOS, Health Network Only, Health Network Option, and Medicare Advantage) do not cover the specialized therapeutic chairs, seats, and benches listed above regardless of whether or not the HMO member has a durable medical equipment (DME) benefit. Aetna's HMO plans follow Medicare's coverage rules for these kinds of DME and Medicare does not cover these chairs as they are considered personal convenience items.

   Aetna traditional plans (indemnity, PPO, and Managed Choice POS) consider specialized therapeutic chairs, seats, and benches medically necessary DME to enable the member to perform essential activities of daily living related to the member's health and hygiene, within or outside the home, with minimal or no assistance from others.

   Aetna does not cover chairs, seats, and benches that are not mainly used to perform these essential daily activities, and/or which are normally of use to persons who do not have a disease or injury because they do not meet Aetna's contractual definition of covered DME.Footnote* Please check benefit plan descriptions for details.

   Footnote1* Note: The following are examples of chairs that are not covered DME because they are not mainly used in the treatment of disease or injury, are not primarily medical in nature, and/or are normally of use to persons who do not have a disease or injury:

   • Back rests;
   • Lumex Ortho-Biotic High Back Rocker;
   • Lumex Ortho-Biotic Recliner;
   • Maddapult Assisto-Seat;
   • Massage chairs;
   • Safety car seats (e.g., Convaid Carrot, Columbia, Churchill, Special Tomato, Spica Car seat) - refer to CPB 0623 - Safety Items;
   • Standard (non-adjustable) high chairs;
   • Standard feeder seats without positioning straps;
   • Zero gravity chairs.

4. Related Policies

   • CPB 0271 - Wheelchairs and Power Operated Vehicles (Scooters) - for policy on wheelchairs
   • CPB 0429 - Bathroom and Toilet Equipment and Supplies
   • CPB 0459 - Seat Lifts and Patient Lifts
   • CPB 0623 - Safety Items

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Table:

CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
HCPCS codes covered if selection criteria are met:
Postural support/therapeutic chair, tilt/recline of the postural support/therapeutic chair (for traditional plan) - no specific code
E0950-E1034 (for Traditional plans)	Wheelchair accessories
HCPCS codes not covered for indications listed in the CPB:
Postural support/therapeutic chair, tilt/recline of the postural support/therapeutic chair (for HMO plan) -no specific code
E0950-E1034 (for HMO plans)	Wheelchair accessories
ICD-10 codes covered if selection criteria are met (not all-inclusive):
A52.17	General paresis
L89.0-L89.96	Pressure ulcer [covered for tilt/recline of the postural support/therapeutic chair]
M24.50-M24.59	Contracture of joint [covered for tilt/recline of the postural support/therapeutic chair]
M25.376	Other instability, unspecified foot
M25.39	Other instability, other specified joint
M62.40-M62.49	Contracture of muscle [covered for tilt/recline of the postural support/therapeutic chair]
M62.81	Muscle weakness (generalized)
M62.89	Other specified disorders of muscle [Abnormal muscle tone] [covered for tilt/recline of the postural support/therapeutic chair]
M62.9	Disorder of muscle, unspecified [Abnormal muscle tone] [covered for tilt/recline of the postural support/therapeutic chair]
R26.2	Difficulty in walking, not elsewhere classified
R26.81	Unsteadiness on feet
R26.89	Other abnormalities of gait and mobility
R29.3	Abnormal posture
R53.1	Weakness

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Background

Therapeutic chairs are specialized seating systems that are adapted to accommodate persons with a physical handicaps. Therapeutic chairs may be necessary to allow persons with disabilities to perform transfers or other essential daily activities, or to facilitate their optimal positioning.

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References