E0642 — Standing frame/table system, mobile (dynamic stander), any size including pediatric
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical record documentation that the member has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADL in the home (MRADLs defined as toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home).
- Documentation that the mobility limitation: prevents the member from accomplishing the MRADL entirely; or places the member at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or prevents the member from completing the MRADL within a reasonable time frame.
- Documentation that the member is able to safely use the requested cane, crutch or walker.
- Documentation that the functional mobility deficit can be sufficiently resolved by use of the requested cane, crutch or walker.
Key Coverage Criteria
- 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.
- Standard walker and related accessories 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 MRADL in the home; the member is able to safely use the walker; and the functional mobility deficit can be sufficiently resolved with use of a walker.
- A standard walker may include wheels and glide-type brakes (wheeled walker = 2, 3, or 4 wheels; wheels may be fixed or swivel; fixed height or adjustable height; may or may not include glide-type brakes).
- Pediatric crawlers as DME for disabled children.
- The Mulholland Walkabout as DME for children who have impaired ambulation and who lack trunk stability and balance.
- Prone, supine and upright (floor/mobile) standers (e.g., Rifton Supine, Prone or Dynamic; Squiggles) as DME for children with cerebral palsy or other severe neuromuscular conditions.
3 Active Policies
AETNA-CPB-0481 — Tables and Boards
AETNA-CPB-0505 — Ambulatory Assist Devices: Walkers, Canes, and Crutches
ANTHEM-CG-DME-49 — CG-DME-49 Standing Frames
Related Codes
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