Clinical UM Guideline


Subject:  Lifting Devices for Use in the Home
Guideline #:  CG-DME-23Current Effective Date:  01/14/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

A lift device is used to assist the caregiver(s) in transferring an individual from bed to chair and back or other locations when the individual is unable to assist with the transfer. This document addresses lifting devices for use in the home, including the multi-positional transfer system.

Note: Please see the following related documents for additional information:

Clinical Indications

Medically Necessary: 

A hydraulic/mechanical lift is considered medically necessary for an individual when all of the following criteria are met:

A canvas or nylon sling or seat for a hydraulic/mechanical lift is considered medically necessary as an accessory when ordered as a replacement for the original equipment item and the criteria listed above are met.

A multi-positional transfer system is considered medically necessary in lieu of any of the following mobility assistive equipment, including but not limited to canes, crutches, walkers, rollabout chairs, transfer chairs, manual wheelchairs, power-operated vehicles, or power wheelchairs, when both of the following criteria are met:

Not Medically Necessary: 

A hydraulic/mechanical lift or multi-positional transfer system is considered not medically necessary when the criteria listed above are not met.

An electric lift mechanism is considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
E0621Sling or seat, patient lift, canvas or nylon
E0625Patient lift, bathroom or toilet, not otherwise classified
E0630Patient lift; hydraulic or mechanical, includes any seat, sling strap(s) or pad(s)
E0635Patient lift; electric, with seat or sling
E0636Multipositional patient support system, with integrated lift, patient accessible controls
E0637Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels [when used as a lift or transfer system]
E0639Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories
E0640Patient lift, fixed system, includes all components/accessories
E1035Multi-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs
E1036Multi-positional patient transfer system, extra-wide, with integrated seat, operated by care giver, patient weight capacity greater than 300 lbs
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
   
Discussion/General Information

A lift device is used within the home or place of residence to assist the caregiver(s) in transferring an individual between a bed and a chair, wheelchair, commode, or shower/bath chair and back when the individual is unable to assist with the transfer. A multi-positional transfer system is used to assist the caregiver(s) in transferring an individual who requires the use of a lift along with supine positioning for transfer. Multi-positional transfer systems (for example, Barton Convertibleā„¢ H-250 Chair, Bartonā„¢ Medical Corporation, Austin TX) are intended to facilitate an independent and safe transfer for the caregiver and individuals that have medical conditions that precludes the use of a standard transfer device (i.e. hydraulic/mechanical lift).

The medical necessity of a lift for use in the home setting is based on an evaluation of the individual's needs and capabilities in relation to the following components of the definition of medical necessity:

  1. The lift is clinically appropriate for the diagnosis or treatment of the individual's illness or injury or to improve the functioning of a malformed body member; and
  2. The lift is not primarily for the convenience of the individual, caregiver, physician or other healthcare provider (NGS, 2011).

An electric lift mechanism is considered not medically necessary as an alternative lift mechanism as it is at least as likely to produce equivalent therapeutic results for the treatment of an individual's illness, injury or disease.

The following types of lifts and accessories are considered self-help or convenience items and do not meet the definition of durable medical equipment:

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination for Durable Medical Equipment Reference List. NCD #280.1. Effective May 5, 2005. Available at: http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed on August 19, 2013.
  2. National Government Services, Inc. (NGS). DME MAC Jurisdiction B. Local Coverage Determination (LCD) for Patient Lifts (L27218). Effective February 4, 2011. Available at: http://www.cms.gov/mcd/viewlcd.asp?lcd_id=27218&lcd_version=14&show=all. Accessed on August 19, 2013.
Index

Barton Convertible H-250 Chair
Hoyer Lift
Lift-Aid Chamber Lift
Multi-positional Transfer System
Trans-Aid Lift

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Document History

Status

Date

Action

Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Minor format changes to Discussion and Coding sections. Updated Reference section.
Reviewed11/08/2012MPTAC review. Updated Discussion, Coding, and References.
Reviewed11/17/2011MPTAC review. Updated Discussion and References.
Reviewed11/18/2010MPTAC review. Revised title: Lifting Devices for Use in the Home. Updated references.
Reviewed11/19/2009MPTAC review. Clarified Clinical Indication for lifts, adding "mechanical" to hydraulic lift statements. Removed Place of Service and Case Management sections, addressing in the Discussion section. Further updates to Discussion and References sections. Updated Coding section to include 01/01/2010 HCPCS changes.
Revised11/20/2008MPTAC review. Addition of a medically necessary criteria and not medically necessary indications for a multi-positional transfer system.  Description, Case Management, Discussion, References, Coding and Index updated.
Reviewed11/29/2007MPTAC review. Clinical Indications, not medically necessary statement clarified. References and Index updated. Updated Coding section with 01/01/2008 HCPCS changes.
Reviewed12/07/2006MPTAC review. References updated.
New12/01/2005MPTAC initial document development.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 No Document
Anthem CO/NV

10/29/2004

DME.210Patient Lifts
Anthem CT

10/01/2004

DME Coverage Criteria Document, Section EPatient Lifts and Accessories
WellPoint Health Networks, Inc.

 

 No Document