Medical Policy


Subject:  Standing Frames
Policy #:  DME.00034Current Effective Date:  01/01/2014
Status:ReviewedLast Review Date:  11/14/2013

Description/Scope

A standing frame is an assistive device that provides a position alternative for individuals confined to supine, prone or sitting positions. These devices allow the individual to achieve a standing position and then support the person in the standing position. Standers can be integrated to use with wheelchairs for those in a sitting position. Other types of standing frames are designed for those in a prone or supine position to achieve a standing position. 

Position Statement

Investigational and Not Medically Necessary:

Standing frames are considered investigational and not medically necessary for all indications.

Rationale

The published studies that address standing for individuals with neurological mobility disabilities, (for example, cerebral palsy, spinal cord injuries, and stroke) do not have consistent outcomes. The theory that passive standing enhances hip alignment, bone mineralization, urinary function, respiratory functioning and psychosocial functioning has not been proven in appropriately designed research studies.

Bagley and colleagues (2005) conducted a randomized controlled trial (RCT) of 170 individuals in an inpatient stroke rehabilitation unit. The participants had a clinical diagnosis of stroke, were medically stable and unable to achieve any score on the Trunk Control Test or unable to stand in mid-line without the assistance of two therapists. Two groups, an intervention group (n = 71) and control group (n = 69), received usual stroke unit care but the intervention group also received a minimum of 14 consecutive days of treatment using the standing frame. The primary outcome measure was the Rivermead Mobility Index (RMI). Blinded participant assessments were undertaken at baseline, six weeks, 12 weeks and six months post stroke. There was no statistically significant difference between groups in any of the outcome measures or for resource use. Mann-Whitney U-tests for the RMI change from baseline scores to six weeks, 12 weeks and six months post stroke were p = 0.310; p = 0.970 and p = 0.282, respectively.

Allison and colleague (2007) studied 17 post stroke individuals in a rehabilitation unit. Each participant was randomly allocated into a control group (who received conventional physiotherapy) or a treatment group (who received conventional therapy plus an additional session of standing practice). The period of intervention ranged from 14 to 28 days depending on the individual's length of stay on the unit. The Gross Functional Tool Section of the Rivermead Motor Assessment, the Trunk Control Test and the Berg Balance Scale were used on admission to the study, at weekly intervals during the intervention, and at 12 weeks after discharge. Of the 17 participants recruited, three withdrew from the additional intervention group citing fatigue as a barrier and 15 completed the study. Participants who completed additional standing practice demonstrated higher scores in all motor measures at week 12, but this difference was not statistically significant. There was a statistically significant difference (P < 0.05) in the changes in Berg Balance score when comparing week 1 with week 12 for the group receiving extra standing practice.  The authors concluded that a larger study is required to establish the value of additional standing practice after stroke. This pilot demonstrates that the Gross Functional Tool Section of the Rivermead Motor Assessment and the Berg Balance Scale would be useful in such a study.

Caulton and colleagues (2004) studied severely disabled children with cerebral palsy (CP) to determine whether participation in 50% longer periods of standing (in either upright or semi-prone standing frames) would lead to an increase in the vertebral and proximal tibial volumetric trabecular bone mineral density (vTBMD). Non-ambulant children with CP are prone to low trauma fractures, which are associated with reduced bone mineral density. A heterogeneous group of 26 pre-pubertal children with CP (14 boys, 12 girls; age 4.3-10.8 years) participated and were matched into pairs using baseline vertebral vTBMD standard deviation scores. Children within the pairs were randomly allocated to either intervention (50% increase in the regular standing duration) or control (no increase in the regular standing duration) groups. Pre- and post-trial vertebral and proximal tibial vTBMD was measured by quantitative computed tomography (QCT). The median standing duration was 80.5% (9.5-102%) and 140.6% (108.7-152.2%) of the baseline standing duration in the control group and intervention group respectively. The mean vertebral vTBMD in the intervention group showed an increase of 8.16 mg/cm3 representing a 6% mean increase in vertebral vTBMD. No change was observed in the mean proximal tibial vTBMD. The authors found that a longer period of standing in non-ambulant children with CP improves vertebral, but not proximal, tibial vTBMD.  The authors concluded that such an intervention might reduce the risk of vertebral fractures but is unlikely to reduce the risk of lower limb fractures in children with CP.

Gudjonsdottir and colleagues (2002) in a case series examined how two types of standers affected BMD and behavioral variables in four children of preschool age with severe CP. In phase I of the study, two children stood in a conventional stander and two stood in a new type of motorized (dynamic) stander that provided intermittent weight bearing standing for 30 minutes a day, five days a week for 8 weeks. In phase two, all four subjects stood in both types of stander during three separate test sessions. Measurements of BMD, before and after the program, revealed increases in BMD in both children who used a dynamic stander and one child who used a static stander. Measures of behavioral variables, including behavioral state, reactivity, goal direction and attention span, indicated little or no effect on behavior from use of the different types of stander. These results suggest there is potential value in additional research concerning the effects of static and dynamic standers on both BMD and behavior in children with CP. 

Kecskemethy and colleagues (2008) acknowledged that despite widespread use, little is known about the actual weight borne while in a stander and the impact on BMD. They studied six males and 14 females in an attempt to quantify actual weight bearing while in two types of passive standers. The participants ranged in age from 6 to 21 years, had quadriplegic CP and were non-ambulatory. For each participant, weight bearing was monitored continuously during a routine 30-minute standing session using one of two standers. The total number of monitored sessions was 108. Right and left weight bearing was measured by the use of footplates interfaced with axial load cells. Weight borne during the 108 standing sessions ranged widely from 37 to 101%. Although mechanical loads are important for obtaining and maintaining bone mineralization, the findings of this study showed that skeletal loading is a very complex process not easily evaluated. The benefits of passive standing are dependent upon factors intrinsic to the particular person, (for example, physical status), as well as extrinsic factors, such as the device(s) used, positioning and measurements of clinical outcomes. The authors concluded that the quantity and quality of objective, scientific evidence demonstrating the benefits of weight bearing are varied and not always consistent, indicating the need for further studies to assess the benefits of weight bearing to include an assessment of actual weight borne.

Hough and colleagues (2010) systematically reviewed the published literature addressing the efficacy of interventions, (for example, medical and physical) to improve low bone mineral density (LBMD) in children and adolescents with cerebral palsy (CP). The authors found that the most promising interventions for decreased BMD were weight bearing and bisphosphonates.  However, there are variations in bone development for pre- and post-pubescent individuals with CP. The cause of this variation is unknown and additional large RCTs are needed of both physical and medical approaches.

Background/Overview

A sit-to-stand device allows the individual with upper body strength to achieve a standing position from a wheelchair without assistance. A sling is slipped behind the buttocks and hooked onto the frame of the standing device. The person's legs and feet are placed in supports on the frame. By using a pneumatic pump lever, the person lifts himself/herself to a standing position. A back support is rotated in place to support the individual's back. 

A prone or supine stander is positioned next to the individual, usually next to a bed. The individual is either rolled or transferred to the device with the help of a sling lift. Once positioned on the device, the person's extremities are secured and the device is changed to a vertical (standing) position. 

Standing frames can be categorized by types:

Definitions

Bone mineral density:  A term used to describe the amount of calcium present in bone. 

Prone:  Lying with the front or face downward. 

Reciprocal movement:  Alternate movements of arms and legs seen in walking and other normal movements. 

Rivermead Mobility Index:  A measure of disability related to bodily mobility that evaluates the individual's ability to move her or his own body. 

Supine: Lying on the back or having the face upward.

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. 

When services are Investigational and Not Medically Necessary:

HCPCS 
E0637Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels [when specified as standing system]
E0638Standing frame/table system, one position (e.g., upright, supine, or prone stander), any size including pediatric, with or without wheels
E0641Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels
E0642Standing frame/table system, mobile (dynamic stander), any size including pediatric
E2230Manual wheelchair accessory, manual standing system
E2301Wheelchair accessory, power standing system, any type
  
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
  
References

Peer Reviewed Publications: 

  1. Allison R, Dennett R. Pilot randomized controlled trial to assess the impact of additional supported standing practice on functional ability post stroke. Clin Rehabil. 2007; 21(7):614-619.
  2. Bagley P, Hudson M, Forster A, et al. A randomized trial evaluation of the Oswestry Standing Frame for patients after stroke. Clin Rehabil. 2005; 19(4):354-364.
  3. Caulton JM, Ward KA, Alsop CW, et al. A randomized controlled trial of standing program on bone mineral density in non-ambulant children with cerebral palsy. Arch Dis Child. 2004; 89(2):131-135.
  4. Eng JJ, Levins SM, Townson AF, et al.  Use of prolonged standing for individuals with spinal cord injuries.  Phys Ther. 2001; 81(8):1392-1399.
  5. Goktepe AS, Tugcu I, Yilmaz B, et al. Does standing protect bone density in patients with chronic spinal cord injury? J Spinal Cord Med. 2008; 31(2):197-201.
  6. Gudjonsdottir B, Stemmons Mercer V. Effects of a dynamic versus a static prone stander on bone mineral density and behavior in four children with severe cerebral palsy. Pediatr Phys Ther. 2002; 14(1):38-46.
  7. Hough J, Boyd R, Keating J. Systematic review of interventions for low bone mineral density in children with cerebral palsy. Pediatrics. 2010; 125(3):670-678.
  8. Kecskemethy H, Herman D, May R, et al. Quantifying weight bearing while in passive standers and a comparison of standers. Dev Med Child Neurol. 2008; 50(7):520-523.
  9. Kunkel CF, Scremin AM, Eisenberg B, et al.  Effect of "standing" on spasticity, contracture, and osteoporosis in paralyzed males.  Arch Phys Med Rehabil. 1993; 74(1):73-78.
  10. Mergler S, Evenhuis H, Boot A, et al. Epidemiology of low bone mineral density and fractures in children with severe cerebral palsy: a systematic review. Develop Med  & Child Neurol. 2009; 51(8):773–778. 

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. Arva J, Paleg G, Lange M, et al.  Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) Position on the Application of Wheelchair Standing Devices.  Assist Tech. 2009; 21:161-168.  Available at:  http://www.resna.org/dotAsset/18255.pdf.  Accessed on October 2, 2013.
  2. Center for Medicare and Medicaid Services (CMS).  National Coverage Determination for:  Seat Lifts.  NCD #280.4.  Effective May 1, 1989.  Available at:  http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=221&ncdver=1&SearchType=Advanced&CoverageSelection=Both&NCSelection=NCA%7cCAL%7cNCD%7cMEDCAC%7cTA%7cMCD&ArticleType=Ed%7cKey%7cSAD%7cFAQ&PolicyType=Final&s=---%7c5%7c6%7c66%7c67%7c9%7c38%7c63%7c41%7c64%7c65%7c44&KeyWord=seat+lift&KeyWordLookUp=Title&KeyWordSearchType=And&kq=true&bc=IAAAABAAAAAA&.  Accessed on October 2, 2013.
  3. U.S. Food and Drug Administration 510(k) Premarket Notification Database. EasyStand Evolv (Ivacare Corp., Elyria, OH).  No. K062402. Rockville, MD: FDA. September 21, 2006. Available at: http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K062402 . Accessed on October 2, 2013.
  4. U.S. Food and Drug Administration 510(k) Premarket Notification Database. Rabbit Mobile Standing Frame. No. K030882. Rockville, MD: FDA. April 4, 2003. Available at: http://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K030882 . Accessed on October 2, 2013.
  5. Wang CH, Bonnemann CG, Rutkowski A, et al.  Consensus Statement on Standard of Care for Congenital Muscular Dystrophies.  J Child Neurol. 2010; 25(12):1559-1581.
Index
EasyStand Evolv
Rabbit Mobile Standing Frame
Standing Frames 

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
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review.  No change to position statement. References were updated.  Updated Coding section with 01/01/2014 HCPCS descriptor changes for E2301.
Reviewed11/08/2012MPTAC review.  No change to position statement. References were updated.
Reviewed11/17/2011MPTAC review. No change to position statement. Rationale, References updated.  Updated Coding section with 01/01/2012 HCPCS descriptor revisions.
Reviewed11/18/2010MPTAC review.
Reviewed11/19/2009MPTAC review. References and Coding updated.
New11/20/2008MPTAC initial document development.