E2617, Custom fabricated wheelchair back cushion, any size, including any type
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; for DMEPOS base items requiring a Written Order Prior to Delivery (WOPD) the supplier must have a signed SWO/WOPD before delivery.
- For DMEPOS base items that require a WOPD and have separately billed options/accessories/supplies, the WOPD must list the base item and may list the associated items prior to delivery.
- A comprehensive written evaluation by a licensed/certified physical therapist or occupational therapist is required for custom fabricated cushions and must clearly explain why a prefabricated seating system is insufficient; the PT/OT may have no financial relationship with the supplier.
- Prefabricated or brand-name custom cushions require written coding verification from the PDAC contractor and must meet the Coding Guidelines stated in the Policy Article; absence of PDAC verification or nonconformance will result in denial.
Key Coverage Criteria
- A general use seat cushion (E2601, E2602) or general use back cushion (E2611, E2612) is covered only when the beneficiary has a covered manual wheelchair or a covered power wheelchair with a sling/solid seat and back that meets Medicare coverage criteria.
- A power wheelchair (with sling/solid seat/back) provided with a general use cushion will be covered instead of a Captain's Chair when the cushion is provided with a covered power wheelchair base that is not available in a Captain's Chair model (K0839,K0840,K0843,K0860,K0861,K0862,K0863,K0864,K0890,K0891).
- A power wheelchair (with sling/solid seat/back) provided with a general use cushion will be covered instead of a Captain's Chair when a skin protection and/or positioning seat or back cushion that meets coverage criteria is also provided.
- A prefabricated skin protection seat cushion (E2603, E2604, E2622, E2623) is covered when the beneficiary has a covered manual wheelchair or power wheelchair with a sling/solid seat/back and has a current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface, or has absent/impaired sensation in the contact area or inability to perform a functional weight shift.
- A prefabricated positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), or positioning accessory (E0953, E0955, E0956, E0957, E0960) is covered when the beneficiary has a covered manual wheelchair or power wheelchair with a sling/solid seat/back and has any significant postural asymmetries.
- A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered when the beneficiary meets the coverage criteria for both a skin protection seat cushion and a positioning seat cushion.
7 Active Policies
ANTHEM-CG-DME-34, CG-DME-34 Wheeled Mobility Devices: Wheelchair Accessories
L33312, Wheelchair Seating
AMBETTER-CP.MP.99, Wheelchair Seating
BCBSIL-DME101.010, Wheelchairs and Accessories
BCBSMT-DME101.010, Wheelchairs and Accessories
Related Codes
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