CG-DME-36 Pediatric Gait Trainers Form

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.