A general use seat cushion and a general use wheelchair back cushion are covered for a beneficiary who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the beneficiary does not have a covered wheelchair, then the cushion will be denied as not reasonable and necessary. If the beneficiary has a POV or a power wheelchair with a captain's chair seat, the cushion will be denied as not reasonable and necessary.
For beneficiaries who meet coverage criteria for a power wheelchair and who do not have special skin protection or positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be covered if either criterion 1 or criterion 2 is met:
1. The cushion is provided with a covered power wheelchair base that is not available in a Captain’s Chair model; or
2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.
If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion will be denied as not reasonable and necessary.
If the beneficiary has a POV or a power wheelchair with a captain's chair seat, a separate seat and/or back cushion will be denied as not reasonable and necessary.
A skin protection seat cushion is covered for a beneficiary who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has either of the following (a or b):
a) Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or
b) Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article. ICD-10 code list.
A positioning seat cushion, positioning back cushion , and positioning accessory are covered for a beneficiary who meets both of the following criteria:
1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and
2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b):
a) A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or
b) A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article.
A combination skin protection and positioning seat cushion is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the LCD-related Policy Article.)
A headrest is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system.
If the beneficiary has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning accessory will be denied as not reasonable and necessary.
If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided and if the stated coverage criteria are not met, it will be denied as not reasonable and necessary.
If a positioning back cushion is provided for a beneficiary who does not meet the stated coverage criteria, it will be denied as not reasonable and necessary.
If a positioning accessory is provided and the criteria are not met, the item will be denied as not reasonable and necessary.