CMS National Coverage Policy
CMS Pub. 100-3, Medicare National Coverage Determinations Manual,
Chapter 1, Section 280.4
Indications and Limitations of Coverage and/or Medical Necessity
For the items addressed in this medical policy, the criteria for
"reasonable and necessary" are defined by the following indications
and limitations of coverage and/or medical necessity.For any item to
be covered by Medicare, it must 1) be eligible for a defined Medicare
benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a
malformed body member, and 3) meet all other applicable Medicare
statutory and regulatory requirements. For the items addressed in this
local coverage determination, the criteria for "reasonable and
necessary", based on Social Security Act § 1862(a)(1)(A) provisions,
are defined by the following indications and limitations of coverage
and/or medical necessity
For an item addressed in this policy to be covered by Medicare, a
written signed and dated order must be received by the supplier prior
to delivery of the item. If the supplier delivers the item prior to
receipt of a written order, it will be denied as noncovered. If the
written order is not obtained prior to delivery, payment will not be
made for that item even if a written order is subsequently obtained.
If a similar item is subsequently provided by an unrelated supplier
who has obtained a written order prior to delivery, it will be
eligible for coverage.
A seat lift mechanism is covered if all of the following criteria are
- The patient must have severe arthritis of the hip or knee or
have a severe neuromuscular disease.
- The seat lift mechanism must be a part of the physician's course
of treatment and be prescribed to effect improvement, or arrest or
retard deterioration in the patient's condition.
- The patient must be completely incapable of standing up from a
regular armchair or any chair in their home. (The fact that a
patient has difficulty or is even incapable of getting up from a
chair, particularly a low chair, is not sufficient justification for
a seat lift mechanism. Almost all patients who are capable of
ambulating can get out of an ordinary chair if the seat height is
appropriate and the chair has arms.)
- Once standing, the patient must have the ability to ambulate.
Coverage of seat lift mechanisms is limited to those types which
operate smoothly, can be controlled by the patient, and effectively
assist a patient in standing up and sitting down without other
assistance. Excluded from coverage is the type of lift which operates
by spring release mechanism with a sudden, catapult-like motion and
jolts the patient from a seated to a standing position.
The physician ordering the seat lift mechanism must be the treating
physician or a consulting physician for the disease or condition
resulting in the need for a seat lift. The physician's record must
document that all appropriate therapeutic modalities (e.g.,
medication, physical therapy) have been tried and failed to enable the
patient to transfer from a chair to a standing position.
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