A4635 — Underarm pad, crutch, replacement, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have a signed WOPD before delivery of the item.
- A Standard Written Order (SWO) must be received by the supplier before a claim is submitted for the item.
- When separately billed options/accessories/supplies accompany a base DMEPOS item that requires a WOPD, the WOPD must list the base item (and may list associated items) prior to delivery.
- Suppliers must maintain proof of delivery (POD) documentation and make it available to the Medicare contractor upon request.
Key Coverage Criteria
- An item is covered only if it is in a defined Medicare benefit category, is reasonable and necessary for diagnosis/treatment or to improve function of a malformed body member, and meets all other Medicare statutory and regulatory requirements.
- Canes (E0100, E0105) and crutches (E0110, E0111, E0112, E0113, E0114, E0116) are covered if the beneficiary has a mobility limitation that significantly impairs participation in one or more mobility-related activities of daily living (MRADL) in the home.
- A mobility limitation exists when it prevents accomplishing the MRADL entirely, places the beneficiary at a reasonably determined heightened risk of morbidity or mortality while attempting the MRADL, or prevents completion of the MRADL within a reasonable time frame.
- The beneficiary must be able to safely use the cane or crutch.
- The beneficiary's functional mobility deficit must be sufficiently resolved by use of a cane or crutch.
- Canes, quad canes, and crutches are medically necessary if all of the following criteria are met: The member has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home (toileting, feeding, dressing, grooming, and bathing); the member is able to safely use the cane or crutch; and the functional mobility deficit can be sufficiently resolved by use of a cane or crutch.
2 Active Policies
L33733 — Canes and Crutches
J19
AETNA-CPB-0505 — Ambulatory Assist Devices: Walkers, Canes, and Crutches
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.