E0243 — Toilet rail, each
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation that the member is bed-confined or room-confined when claiming bed pans, bed baths, or urinals as medically necessary (policy definition: 'room-confined' means the member’s condition is such that leaving the room is medically contraindicated; confinement to home without toilet facilities or confinement to a floor of the home without a bathroom may be equated to room confinement).
- Physician statement/clinical documentation that the member is physically incapable of using regular toilet facilities (for commode coverage).
- Documentation that the member is confined to a single room, or confined to one level of the home with no toilet on that level, or confined to the home and there are no toilet facilities in the home (to substantiate need for commode).
- Weight documentation (e.g., clinical record showing measured weight) to support extra wide/heavy commode chair (member weighs 300 pounds or more).
Key Coverage Criteria
- Raised toilet seats are considered medically necessary (Traditional plans) if member is unable to rise from toilet seat without assistance.
- Toilet seat lift (erector) is considered medically necessary if member is unable to rise from toilet seat without assistance.
- Sitz bath is considered medically necessary for infection or injury of the perineal area.
- ICD-10 diagnoses listed as 'covered if selection criteria are met' (examples include but are not limited to: A52.17 General paresis [covered for tilt/recline rehab shower commode chair]; G12.21 Amyotrophic lateral sclerosis; G35 Multiple sclerosis; G80.0-G80.9 Cerebral Palsy; G82.20-G82.22 Paraplegia; G82.50-G82.54 Quadriplegia; G83.0-G83.34 Other paralytic syndromes; L89.0-L89.96 Pressure ulcer [covered for tilt/recline rehab shower commode chair]; M24.50-M24.59 Contracture of joint [covered fo [...]
- Aetna's HMO-based and health network plans generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom; most DME items used in the bathroom are considered by Medicare to be personal convenience items. Consistent with Medicare rules, Aetna's HMO-based plans consider certain DME toilet items (commodes, bed pans, etc.) medically necessary if the member is bed-confined or room-confined.
- Aetna's traditional plans (indemnity, PPO, and Managed Choice POS) consider DME used in the bathroom medically necessary if the DME is primarily medical in nature, not normally of use in the absence of illness and injury, and if it is necessary for daily activities related to health and personal hygiene.
6 Active Policies
AETNA-CPB-0429 — Bathroom and Toilet Equipment and Supplies
BCBSIL-DME101.000 — Durable Medical Equipment (DME) Reference List
BCBSMT-DME101.000 — Durable Medical Equipment (DME) Reference List
BCBSNM-DME101.000 — Durable Medical Equipment (DME) Reference List
BCBSOK-DME101.000 — Durable Medical Equipment (DME) Reference List
Related Codes
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