S78.119A — Complete traumatic amputation at level between unspecified hip and knee, initial encounter
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- ICD-10-CM diagnosis code(s) documenting the current or past pressure ulcer as listed in the policy's "ICD-10-CM Diagnosis Codes That Support Medical Necessity" section
- Clinical documentation in the medical record verifying presence or history of a pressure ulcer and its location corresponding to the seating contact area
- Comprehensive, written evaluation by a licensed/certified medical professional (PT or OT) that clearly explains why a prefabricated seating system is not sufficient to meet seating and positioning needs.
- Documentation that the member meets all criteria for the applicable prefabricated seat cushion or prefabricated positioning back cushion.
Key Coverage Criteria
- General use seat cushion (E2601, E2602) and general use wheelchair back cushion (E2611, E2612) for an approved manual or power wheelchair with a sling or solid seat or back.
- Skin-protection seat cushion (E2603, E2604, E2622, E2623) for an approved manual or power wheelchair with a sling or solid seat/back when additional clinical criteria are met.
- Current pressure ulcer on the area of contact with the seating surface
- Past history of a pressure ulcer on the area of contact with the seating surface
- Absent or impaired sensation in the area of contact with the seating surface.
- Inability to carry out a functional weight shift due to one of the following diagnoses: spinal cord injury (quadriplegia or paraplegia), other spinal cord disease, multiple sclerosis or other demyelinating disease, cerebral palsy (including athetoid cerebral palsy), anterior horn cell diseases including amyotrophic lateral sclerosis, post‑polio paralysis, traumatic brain injury resulting in quadriplegia, spina bifida, childhood cerebral degeneration, Alzheimer's disease, Parkinson's disease, dem [...]
1 Active Policy
AMBETTER-CP.MP.99 — Wheelchair Seating
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.