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Anthem Blue Cross ConnecticutCommercial Clinical Policy

Anthem Blue Cross Connecticut CG-DME-36 Pediatric Gait Trainers Form


pediatric gait trainer with trunk support

Indications

(821739) Is the patient 18 years of age or younger? 
(821740) Does the patient require moderate to maximum support for ambulation due to conditions like spinal cord injury, traumatic brain injury, cerebral palsy, neuromuscular disease, or spina bifida? 
(821741) Can the patient demonstrate the ability to ambulate with the device? 

Contraindications

(821742) Does the patient not meet any one of the above listed criteria? 
Effective Date

06/28/2023

Last Reviewed

05/11/2023

Original Document

  Reference



This document addresses the indications for a pediatric gait trainer with trunk support, a device similar to a walker that is intended to provide balance stability and postural control in children who require moderate to maximum support for walking. This policy does not address electromechanical or robotic-assisted devices.

Note: For information regarding powered gait training devices, please see the following:

  • OR-PR.00006 Powered Robotic Lower Body Exoskeleton Devices

Clinical Indications

Medically Necessary:

A pediatric gait trainer with trunk support is considered medically necessary for an individual who meets all of the following criteria:

  1. Is 18 years of age or younger; and
  2. Requires moderate to maximum support for ambulation (for example, because of an injury such as spinal cord or traumatic brain injury or chronic illness: cerebral palsy, neuromuscular disease, or spina bifida); and
  3. Demonstrates the ability to ambulate with the device.

Not Medically Necessary:

A pediatric gait trainer with trunk support is considered not medically necessary when the criteria are not met.