Wheelchair Cushions and Seating - DME.WC.102.A

EviCore covers wheelchair seating and cushions (skin‑protection, positioning, combination, prefabricated general‑use and, if criteria met, custom‑fabricated cushions; solid seat support E2231 for manual chairs) when the member meets medical necessity for a manual or power wheelchair and seating is required for functioning at home, and excludes commode seats for comfort, cushions for transport chairs or captain’s seats, powered seat cushions (E2610), and items provided primarily for comfort/hygiene. Coverage requires documentation of wheelchair medical necessity and home ADL need plus specific clinical evidence (skin protection: current/prior pressure ulcer at the contact site, absent/impaired sensation, or inability to perform a functional weight shift; positioning: trunk/pelvic anatomical change from a medical/neuromuscular condition; combination = both), and custom cushions additionally require a wheelchair evaluation by a clinician with seating expertise and justification why prefabricated options are inadequate.