E0637 — Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No explicit detailed documentation checklist is provided in the CPB; coverage is contingent on meeting the stated 'selection criteria' and medical necessity for the listed indications.
- For home use of a tilt table: arrangements should be made to have an appropriate attendant (e.g., nurse, home health aide, trained family member) to supervise its use.
- Benefit plan level limitation: 'Most Aetna benefit plans exclude coverage of exercise equipment. Please check benefit plan descriptions.' (Documentation of plan benefits may be required.)
- The policy references that certain codes (Column II) are included in the allowance for corresponding Column I codes when provided at the same time; coding/crosswalk documentation per the table must be followed.
Key Coverage Criteria
- Postural drainage boards - for members with chronic pulmonary conditions;
- Prone boards (e.g., Prone Board Standing System, Rifton Supine Board) - for members with neuromuscular conditions such as cerebral palsy or quadriplegia, who need a prone board to assist them in being placed in an upright position;
- Stand Aid/Stand Alone - to improve lower body strength for members with paraplegia and other neuromuscular conditions who are unable to rise from a seated to standing position without assistance and have some residual strength in the hips or legs such that that they can maintain the standing position.
- Standers, standard nonpowered - for members with spastic quadriplegia and other neuromuscular conditions who have impaired ability to stand, but once standing can maintain this position due to residual strength in the hips, legs and lower body. Standers provide limited assistance to permit the member to rise to a standing position, allowing the member to increase or maintain lower body strength by achieving the standing position.
- Tilt tables - for reconditioning of persons with orthostatic hypotension, such as due to stroke, spinal cord injury, prolonged immobilization, or advanced age;
- Transfer board - for members with medical conditions that limit their ability to transfer from wheelchair to bed, chair, toilet, etc.
4 Active Policies
AETNA-CPB-0271 — Wheelchairs and Power Operated Vehicles (Scooters)
AETNA-CPB-0481 — Tables and Boards
ANTHEM-CG-DME-49 — CG-DME-49 Standing Frames
ANTHEM-CG-DME-23 — CG-DME-23 Lifting Devices for Use in the Home
Related Codes
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