Children's Mobility and Positioning Equipment

Description of Procedure or Service

Children with chronic disabilities, such as cerebral palsy or spina bifida, often require multiple pieces of adaptive equipment (or assisted technology) to assist in their daily activities. Requests for equipment may include some of the following:

• Mobility devices (wheelchair, stroller, scooter) 
• Positioning devices such as standers (prone, supine, upright and dynamic); corner chair, bolster chair, feeding chair, bolsters, wedges, sidelyers)
• Adapted toys (floor scooters, tricycles, computer switch toys)

Related Policy:

Durable Medical Equipment (DME)

Policy

BCBSNC will provide coverage for Children’s Mobility and Positioning Equipment when it is determined to be medically necessary because the medical criteria and guidelines shown below are met.   

Benefits Application

This medical policy relates only to the services or supplies described herein. Some mobility and positioning equipment, including but not limited to standing frames, is specifically excluded under most health benefit plans. Durable medical equipment that serves no medical purpose or that is primarily for comfort or convenience is also excluded under most health benefit plans. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this medical policy. See Other Services for Durable Medical Equipment. The supplier of the durable medical equipment must be acceptable to the Plan in order to be eligible for reimbursement. The DME supplier must meet eligibility and/or credentialing requirements as defined by the Plan to be eligible for reimbursement

When Children's Mobility and Positioning Equipment is Covered

Determination of medical necessity will be made based on the following criteria:

1. The child has a condition in which there is a disease process or injury which significantly impairs normal mobility expected for age.
2. Manual wheelchairs and standard strollers cannot be adapted to safely meet child’s positioning needs.
3. There has been an evaluation, either in a specialized seating /mobility clinic or by a physician and therapist who are knowledgeable about prescribing mobility devices for long-term disability. This evaluation must be completed by a professional, as indicated above, independent from the vendor supplying the equipment.
4. The child’s plan of care indicates that the primary use of the equipment is for mobility purposes and not for leisure, recreation or sports activities or non-covered activities (defined in the section below).
5. The child has a documented successful use of the device and the therapist has documented rationale for selection of the specific product requested over available alternatives.

When Children's Mobility and Positioning Equipment is not covered

1. When it is determined to be not medically necessary. 
2. Adapted toys (floor scooters, tricycles, or computer switch toys) are not considered durable  equipment since they do not serve a medical purpose. Please refer to the Member's Benefit Booklet for exclusions relating to recreational and leisure equipment.
3. Standard Strollers are not are not considered durable medical equipment since they do not serve a medical purpose. Please refer to the Member's Benefit Booklet for exclusions relating to recreational and leisure equipment.
4. Any equipment, option or accessory that is primarily for the purpose of allowing the member to perform leisure, recreation or sports activities, sitting in a motorized vehicle, or for the sole purpose of attending school will be considered noncovered. Please refer to the Member's Benefit Booklet for exclusions relating to recreational, leisure, and educational equipment.
5. Electric patient lifts (e.g., Saralift), Seat Lift Chair Mechanisms, Ceiling Lifts, or Patient Support Mechanisms are considered convenience items and therefore not covered. Please refer to the Member's Benefit Booklet for exclusions relating to devices and equipment used for convenience or environmental accommodation.

Policy Guidelines

• Approval will be determined based on documentation of medical necessity. See Documentation Information below. 
• Frequency, duration and place of intended use must be specified. 
• Approval is generally limited to one mobility device and one positioning device every 2 years. Requests should indicate that the potential for growth or anticipated functional change in the child can be reasonably accommodated for 2 years.  

Billing/Coding/Physician Documentation Information 

This policy may apply to the following codes. Inclusion of a code in this section does not guarantee that it will be reimbursed. For further information on reimbursement guidelines, please see Administrative Policies on the Blue Cross Blue Shield of North Carolina web site at www.bcbsnc.com. They are listed in the Category Search on the Medical Policy search page.

Applicable codes: E0638, E0641, E0642, E0950-E1298, E2201-E2399, E2601-E2621, E8000, E8001, E8002, K0001-K0195, K0462, K0669

The following documentation is required to determine medical necessity:

• Child’s diagnosis and prognosis,
• The child’s specific functional disabilities that will be improved by the requested equipment,
• The child’s ability to appropriately and functionally use and benefit from the equipment,
• The functional goals for use of the equipment that relate to improved medical or functional status; and
• The medical conditions that are expected to be prevented by use of the equipment and the indications that the child is at risk for development of these conditions (such as flexion contractures). BCBSNC may request medical records for determination of medical necessity. When medical records are requested, letters of support and/or explanation are often useful, but are not sufficient documentation unless all specific information needed to make a medical necessity determination is included.

Scientific Background and Reference Sources

Physical Therapy Consultant - 1/96

BCBSNC Matrix Program - Certificate language Medical Policy Advisory Group - 1/99

Specialty Matched Consultant Advisory Panel - 9/00

Medical Policy Advisory Group - 10/2000 Specialty Matched Consultant Advisory Panel - 7/2002

Medical Policy Advisory Group- 6/2004

Specialty Matched Consultant Advisory Panel- 10/2010

Specialty Matched Consultant Advisory Panel- 9/2011

Specialty Matched Consultant Advisory Panel- 9/2012

Specialty Matched Consultant Advisory Panel- 9/2013

Specialty Matched Consultant Advisory Panel- 9/2014

Specialty Matched Consultant Advisory Panel- 9/2015

Medical Director review 9/2015 Specialty Matched Consultant Advisory Panel- 9/2016

Medical Director review 9/2016

Specialty Matched Consultant Advisory Panel- 9/2017 Medical Director review 9/2017

Children’s Mobility and Positioning Equipment

Specialty Matched Consultant Advisory Panel- 9/2018

Medical Director review 9/2018

Specialty Matched Consultant Advisory Panel 9/2019

Medical Director review 9/2019

Specialty Matched Consultant Advisory Panel 9/2020

Medical Director review 9/2020

Specialty Matched Consultant Advisory Panel 9/2021

Medical Director review 9/2021

Specialty Matched Consultant Advisory Panel 9/2022

Medical Director review 9/2022

Specialty Matched Consultant Advisory Panel 9/2023

Medical Director review 9/2023

Policy Implementation/Update Information

6/96 Original Policy issued

5/97 Revised. Added DME Supplier information and Source as contract language.

1/99 Reaffirmed: Medical Policy Advisory Group

7/99 Reformatted, Medical Term Definitions added.

7/00 System coding changes.

10/00 Specialty Matched Consultant Advisory Panel. No change recommended in criteria. System coding changes. Medical Policy Advisory Group review. No change in criteria. Approve. 

11/01 Strollers added to "when it is not covered" section.

4/02 Revised under "when it is not covered" section to include "strollers are not medically necessary and will be considered noncovered".

8/02 Specialty Matched Consultant Advisory Panel review

7/12/2002. Revised Description of Procedure or Service section to remove the statements on communication systems.

3/04 Benefits Application and Billing/Coding sections updated for consistency.

7/15/04 Medical Policy Advisory Group review. No changes to criteria. Codes (K0650-K0669) and information added to Billing and Coding Section.

1/05/06 Added policy number to "Key Words." Updated HCPCS codes to reflect 2006 code changes.

8/28/06 Added medical necessity criteria to section "When Children’s Mobility and Positioning Equipment is covered" to indicate this DME is covered when the child has a condition in which there is a disease process or injury which significantly impairs normal mobility expected for age; when manual wheelchairs and standard strollers cannot be adapted to meet child’s positioning needs; when there has been an evaluation, either in a specialized seating/mobility clinic or by a physician and therapist independent from the vendor supplying the equipment; and when the child’s plan of care indicates that the primary use of the equipment is for mobility purposes and not for leisure, recreation or sports activities. Additional information added to section "When Children’s Mobility and Positioning Equipment is not covered" that states any equipment, option or accessory that is primarily for the purpose of allowing the member to perform leisure, recreation or sports activities is not covered. Also, electric patient lifts, seat lift chair mechanisms, ceiling lifts, patient support mechanisms, sit to stand or standing frame systems are considered convenience items and are not covered. HCPCS codes updated. Speciality Matched Consultant Advisory Panel review

6/28/06. (adn)

7/28/08 Bulleted lists in the Covered and Non Covered section converted to numbered lists. In the Covered section, Item 4 changed to read: "The child’s plan of care indicates that the primary use of the equipment is for mobility purposes and not for leisure, recreation or sports activities or non-covered activities." Added Item 5 that reads, "The child has a documented successful use of the device and the therapist has documented rationale for selection of the specific product requested over available alternatives." In the Not Covered section, Item 4 changed to read: "Any equipment, option or accessory that is primarily for the purpose of allowing the member to perform leisure, recreation or sports activities, sitting in a motorized vehicle, or for the sole purpose of attending school will be considered noncovered." In the Policy Guidelines section, added the following statement, "Frequency, duration and place of intended use must be specified." Speciality Matched Consultant Advisory Panel review

6/19/08. (adn)

6/22/10 Policy Number(s) removed (amw)

10/22/10 Specialty Matched Consultant Advisory Panel. (lpr)

10/11/11 Specialty Matched Consultant Advisory Panel review

9/28/2011. Added benefit exclusion for standing frames to “Benefits Application” section.(lpr)

1/1/2012 Added E0638 to Billing/Coding section for 2012 code update. Standing frames are benefit exclusion. (lpr)

10/16/12 Revised wording Under “When Not Covered” section for statements 1-3 related to benefit exclusions. Changed language from “not medically necessary” to “not considered durable medical equipment since they do not serve a medical purpose.” Also removed reference to standing frames since this is now a standard benefit exclusion. Specialty Matched Consultant Advisory Panel review

9/21/2012. No change to policy statement. (lpr)

2/12/13 Deleted HCPCS code E1340 from the Billing/Coding section. (lpr)

10/15/13 Specialty matched consultant advisory panel review

9/18/2013. Added the word “safely” to statement #2 under “When Covered” section. (lpr)

11/26/13 Under Description section 2nd bullet: relocated the word “prone” and placed in parentheses with “supine, upright and dynamic” as other examples of standers. Medical director review

11/2013. (lpr) 10/14/14 Specialty matched consultant advisory panel review

9/2014. No change to policy statement. (lpr) (td)

10/30/15 Specialty Matched Consultant Advisory Panel review

9/30/2014. Medical Director review

9/2015. Policy intent remains unchanged. (td)

10/25/16 Specialty Matched Consultant Advisory Panel review

9/30/2016. Medical Director review

9/2016. (jd)

10/13/17 Specialty Matched Consultant Advisory Panel review

9/2017. Medical Director review

9/2017. (jd) 

10/12/18 Specialty Matched Consultant Advisory Panel review

9/2018. Medical Director review

9/2018. (jd)

10/15/19 Specialty Matched Consultant Advisory Panel review

9/2019. Medical Director review 9/2019. (jd)

10/1/20 Specialty Matched Consultant Advisory Panel review

9/2020. Medical Director review

9/2020. (jd)

10/1/21 Specialty Matched Consultant Advisory Panel review

9/2021. Medical Director review

9/2021. (jd)

10/18/22 References updated. Specialty Matched Consultant Advisory Panel review

9/2022. Medical Director review

9/2022. (tm)

10/10/23 References updated. Specialty Matched Consultant Advisory Panel review

9/2023. Medical Director review

9/2023. (tm)