Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the patient would be bed confined.

A patient lift described by codes E0630, E0635, E0639, or E0640 is covered if the basic coverage criteria are met. If the coverage criteria are not met, the lift will be denied as not medically necessary.

A multi-positional patient support/transfer system (E0636, E1035, E1036) is covered if both of the following criteria 1 and 2 are met:

  1. The basic coverage criteria for a lift are met; and
  2. The patient requires supine positioning for transfers.

If criterion 1 is not met, codes E0636, E1035, and E1036 will be denied as not medically necessary. If criterion 1 is met but criterion 2 is not met, payment will be made for the least costly medically appropriate alternative, E0630.

If coverage is provided for code E1035 or E1036, payment will be discontinued for any other mobility assistive equipment, including but not limited to: canes, crutches, walkers, rollabout chairs, transfer chairs, manual wheelchairs, power-operated vehicles, or power wheelchairs.

Code E0621 is covered as an accessory when ordered as a replacement for a covered patient lift.