Seat Lift Mechanism, Patient Lifts and Standing Devices - (0343) Form

Coverage Policy

The following Coverage Policy applies to health benefit plans administered by Cigna Companies. Certain Cigna Companies and/or lines of business only provide utilization review services to clients and do not make coverage determinations. References to standard benefit plan language and coverage determinations do not apply to those clients.

Coverage Policies are intended to provide guidance in interpreting certain standard benefit plans administered by Cigna Companies. Please note, the terms of a customer’s particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Policies are based. For example, a customer’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Policy. In the event of a conflict, a customer’s benefit plan document always supersedes the information in the Coverage Policies.

In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Policies and; 4) the specific facts of the particular situation.

Each coverage request should be reviewed on its own merits. Medical directors are expected to exercise clinical judgment and have discretion in making individual coverage determinations.

Coverage Policies relate exclusively to the administration of health benefit plans. Coverage Policies are not recommendations for treatment and should never be used as treatment guidelines.

In certain markets, delegated vendor guidelines may be used to support medical necessity and other coverage determinations.

This Coverage Policy addresses technologies such as seat lift mechanisms, patient lifts, multi-positional transfer systems, and standing devices which are used to ease patient transfers, prevent patient and/or caregiver injuries, and to promote other health benefits.

Coverage Policy

Coverage for a seat lift mechanism, patient lift, multi-positional transfer system or standing device varies across plans. Refer to the customer’s benefit plan document for coverage details. Under many benefit plans coverage of lifting devices is limited to a manual hydraulic lift.

Patient lifts (mechanical or motorized), seat lifts (mechanical or motorized), seat lift mechanisms, patient transfer systems (including multi-positional systems), and standing devices/systems are specifically excluded under most benefit plans and therefore the items referenced below are generally not covered.

If coverage is available for ANY of the following devices the following conditions of coverage apply.

• A patient lift (electrical, mechanical, and hydraulic) (HCPCS code E0630, E0635, E0639) is considered medically necessary when ALL of the following criteria are met:
  1. transfer between bed and a chair, wheelchair or commode requires the assistance of more than one person
  2. individual has a medical condition that without the use of a lift, the individual would be confined to bed (e.g., paralysis, spinal cord injury, neuromuscular disease)
  3. an adequately trained person, other than the individual, is available to help operate the lift
• A seat lift mechanism* (HCPCS code E0627, E0629) is considered medically necessary when ALL of the following conditions are met:
  • Individual has the ability to ambulate once standing.

Individual has a condition that renders them completely incapable of standing up from any chair in their home (e.g., severe arthritis of the hip, severe arthritis of the knee, severe neuromuscular disease). Appropriate therapeutic modalities designed to enable the individual to transfer from a chair to a standing position (e.g., medications, physical therapy, occupational therapy) have been attempted without lasting success. Coverage for a seat lift mechanism is limited to the seat lift mechanism only, even if the mechanism is incorporated into a chair.

A multi-positional transfer system (HCPCS code E0636, E1035, E1036) is considered medically necessary when BOTH of the following criteria are met:

• individual meets criteria for a patient lift
• individual has a medical condition requiring a supine transfer

A combination transfer and mobility device (i.e., Rifton TRAM, Rifton E-Pacer) (HCPCS code E1399) is considered medically necessary when BOTH of the following criteria are met:

• individual meets criteria listed above for a patient lift
• individual meets criteria for a gait trainer: meets criteria for standard walker and requires moderate to maximum truncal support for walking and has demonstrated the capability of walking with the use of the device

Please refer to Cigna Coverage Policy 0050 Ambulatory Assistance Devices for additional information on the criteria of standard walker and gait trainer.

The following standing device systems are considered medically necessary when criteria are met:

• A non-powered, single-position standing device (HCPCS code E0638) when ALL of the following criteria are met:

1. The individual is unable to ambulate or stand independently because of a neuromuscular condition but has sufficient residual strength in the lower extremities (e.g., hips and legs) to allow for use of the device.
2. A standing position cannot be successfully achieved even with the use of physical therapy or other assistive devices.
3. The individual has completed appropriate standing device training and has demonstrated an ability to safely use the device.
4. Use of the device is expected to allow meaningful improvement in at least ONE of the following: performance of activities of daily living (ADLs), functional use of the arms or hands, functional head and trunk control, digestive, respiratory, circulatory or excretory function, skin integrity, by off-loading weight through standing (e.g., relief of pressure ulcers not achievable by other means).

A non-powered mobile standing frame system (HCPCS code E0642) when criteria are met for a non-powered single-position standing device and the individual has the upper arm strength required to self-propel the device.

A non-powered multipositional standing frame system (HCPCS code E0641) when criteria are met for a non-powered single-position standing device and the individual has a medical condition that requires frequent changes in positioning.

REPLACEMENT & DUPLICATE EQUIPMENT

In general, duplicate equipment is considered a convenience item and therefore not medically necessary. Replacement of a medically necessary patient lift, seat lift mechanism, multipositional transfer system, or standard non-powered standing device is considered only when there is anatomical change or when reasonable wear and tear renders the item nonfunctioning and not repairable and there is coverage for the specific item available under the plan.

NOT MEDICALLY NECESSARY ITEMS

The following items are each considered one or more of the following, even if the item is not specifically excluded under the benefit plan:

• Not primarily medical in nature
• A self-help or convenience item and/or
• Not medically necessary:

• Bathroom lifts and/or toilet lifts
• Combination sit-to-stand frame/table systems
• Electric, motorized, or powered standing devices
• Elevators
• Platform lifts
• Stair gliders
• Stairway chair/stair lifts
• Van lifts
• Lifting, standing or positioning devices that involve fixtures to real property (e.g., ceiling lifts)

General Background

Many medical conditions (e.g., arthritis, muscular dystrophy, other neuromuscular diseases) can lead to limited mobility as a result of pain, joint stiffness or muscle weakness. Often, patients are not able to move from a sitting position to a standing position without the assistance of another person or a device. Technologies such as seat lift mechanisms, patient lifts and standers (e.g., standing devices, prone standers) have been employed to ease patient transfers and prevent patient and/or caregiver injuries.

Patient Lifts

Patient lifts are assistive devices that are intended to assist a caregiver in transferring a patient safely back and forth from a bed to a chair in cases where the patient is immobilized and would otherwise be confined to a bed. These devices function electrically or mechanically/hydraulically (e.g., Hoyer lift) with a sling and/or seat that is placed under the patient (HCPCS code E0630). Indications for standard manual hydraulic patient lift devices (e.g., Hoyer Patient Lift, Invacare Reliant Hydraulic Lift) are limited to conditions in which repositioning is required to affect improvement or to prevent deterioration in the patient's condition.

HCPCS code E0635 is a patient lift, electric, with seat or sling. HCPCS code E0639 describes a device in which the lift mechanism is part of a floor-to-ceiling pole system, not permanently attached to the floor and ceiling, which is used in a room other than the bathroom. HCPCS code E0640 (patient lift, fixed system) describes a device in which the lift mechanism is attached to permanent ceiling tracks or a wall mounting system and which is used in a room other than the bathroom. The lift/transport mechanisms for these devices may be mechanical or electric. This device is considered a deluxe, self-help or convenience item.

Seat Lift Mechanisms

Standing up requires lower limb strength and good dynamic equilibrium, and people with significant weakness and/or impaired balance can have difficulty standing up and sitting down. People who are unable to stand up on their own are at an increased risk of falls and decreased quality of life (Lou, et al., 2021).

Seat lift mechanisms are a type of assistive device used to lift the body from a sitting position to a standing position. The mechanism is also capable of lowering the patient from a standing to a sitting position. Seat lifts are generally recommended only for patients who are able to ambulate once they are standing. The lift mechanism may be either electric or hydraulic and may be either built directly into a chair (HCPCS code E0627) or used as a separate portable device (HCPCS code E0629). Seat lift mechanisms that are considered safe and effective are limited to those which operate smoothly, can be controlled by the patient, effectively assist the patient in standing up and sitting down without other assistance, and are limited to the seat lift mechanism, even if it is incorporated into a chair. Devices that operate by spring release mechanisms with a sudden, catapult-like motion and that jolt the patient from a seated to a standing position are not considered safe and effective.

The Centers for Medicare & Medicaid Services (CMS) Recommendations

The Centers for Medicare & Medicaid Services (CMS) (1989) recommends that criteria for establishing medical necessity for seat lift mechanisms include the following:

• The seat lift must be included in the course of the physician’s treatment.
• It must be likely to effect improvement or to arrest or retard deterioration in the patient’s condition.
• The severity of the patient's condition is such that without the device the patient would be confined to a chair or bed.

Ceiling Lifts

Ceiling lifts may be used with a ceiling track or be a free-standing lift system. The tracks can be located in more than one room of the home, allowing some portability; most ceiling lifts are motorized. Manufacturers propose that positioning is easier with ceiling lifts than with floor-mounted lifts, and, if motorized, the ceiling lifts can be used independently by the user. Ceiling lifts, including motorized lifts, however, are considered convenience items.

Miscellaneous Lifts

Multi-positional transfer systems (e.g., Barton 250 Chair) allow positioning and adjustment so that an individual who is bed-bound can be transferred onto the device in the supine position (HCPCS codes E1035, E1036). Once positioned, the device can be adjusted to a chair-like position with varying degrees of recline and leg elevation. These devices are not electric. While some individuals may have a medical condition that precludes use of a standard device for transfers, such as a hydraulic lift, these multi-positional transfer systems are also aimed at allowing a more independent and safe transfer for patients and caregivers in the home. HCPCS code E0636 is an electric multipositional patient support system with integrated lift, and patient-accessible controls. Stairway chair lifts and stair gliders are devices attached to a track on a stairway to transfer from one level of the home to another on a chair or lift seat. They can be used on straight, curved or spiral stairs to aid in mobility throughout the home. Bathroom lifts used for transferring a patient onto a toilet or into a tub/shower are considered self-help and convenience items. Other commonly used lift devices, including but not limited to, van lifts (used to lift wheelchairs in and out of vans), wheelchair lifts (used to provide access to stairways or automobiles) and platform lifts, do not serve a medical purpose. Many of these types of devices are used to facilitate transportation within the home or in and out of the home and are considered convenience/self-help items.

Standing Devices

Standing devices are items used to assist with achieving a standing position and have been proposed for children and adults with neuromuscular conditions, who are unable to stand or ambulate independently (e.g., cerebral palsy, spinal cord injuries, muscular dystrophy, paraplegia, and quadriplegia). The standing frame provides alternative positioning to sitting in a wheelchair by supporting the person in the standing position. These devices are used to increase patient independence with activities of daily living, improve trunk strength, aid in digestion, improve circulation and upper body balance and strength, and to decrease abnormal muscle tone and reflexes. Standing devices may also be used as components of rehabilitation programs for individuals with spinal cord injuries and other neuromuscular conditions. Standing improves bone mineral density, bowel and bladder functioning, incidence of contractures, and improves skin integrity. These devices can be mechanical or powered devices; some require the use of a caregiver to transfer the individual while other types allow independent transfer. In general, these devices may be categorized as passive, mobile or active.

Passive, Mobile, and Active Standing Devices

Passive devices remain in one place; these devices may have casters but cannot be self-propelled. Mobile standers (HCPCS code E0642) can be self-propelled and require the ability and degree of strength necessary to self-propel a wheelchair. Some of the mobile devices are available with powered mobility.

Active standers allow users to move their arms creating a reciprocal movement of the legs while in a standing position and promote upper extremity strengthening and lower extremity range of motion.

Standing devices may also be referred to by the type of positioning option and include supine, prone, or upright (HCPCS code E0638), multipositional (HCPCS code E0641) and sit-to-stand standers (HCPCS code E0637).

• Supine standers support the back surface of the body and require the least amount of trunk and head control.
• Prone standers are devices that support the front of the body, while the user is supported in various angles.
• Upright standers are used primarily in the vertical position by individuals who have fair to good trunk and head control.
• Multipositional standing devices allow the individual to be placed in either a prone, supine or upright position.

A combination sit-to-stand device is a standing device with a seat lift mechanism aimed at allowing frequent repositioning (sitting to standing, standing to sitting) without assistance. Combination devices use a sling or seat, lifting the user directly from a wheelchair or sitting position to a standing position, either mechanically (e.g., foot pump) or through the use of a motorized control.

Additional items, such as angle-adjustable footplates and anterior chest, knee, and head supports, are often required when using these devices.

Some currently available standing devices have overlapping options with the goal of allowing more positioning possibilities, for example mobile and active standers may also incorporate sit-to-stand options, and some sit-to-stand devices may have added functions, such as those available with a supine stander.

Standers and standing devices are not recommended for individuals with complete paralysis of the lower extremities; lower body range of motion is not greatly improved or maintained with their use. Combination sit-to-stand devices and powered or motorized options are considered self-help or convenience items.

Combination Transfer and Mobility Devices

A combination transfer and mobility device is proposed to be used to assist with lifts, transfers, and gait training. The Rifton TRAM (Rifton Equipment, Rifton, NY) is described by the vendor as intended for a patient unable to transfer or walk independently and is a patient transfer system, a sit-to-stand device and a gait trainer.

The device features a support system that secures the patient with a simple buckle which enables the caregiver to prepare the patient for a safe transfer. According to the product website it notes that unlike other patient transfer devices, there are no slings and requires little or no preparation to transfer clients.

Rifton E-Pacer (Rifton Equipment, Rifton, NY) is a combination transfer and mobility device proposed used to assist with lifts, transfers, and gait training. The vendor website notes that the E-Pacer combines the powerful electric lift column and secure body support of the Rifton TRAM with the key gait training features of the classic Pacer gait trainer.

These devices are considered appropriate for an individual that meets criteria for patient lifts and for gait training as noted in Coverage Policy 0050 Ambulatory Assistance Devices which indicates that a walker with trunk support is covered for an individual who meets coverage criteria for a standard walker and requires moderate to maximum truncal support for walking and has demonstrated the capability of walking with the use of the device. Please refer to Cigna Medical Coverage Policy 0050 Ambulatory Assistance Devices for further information on gait training devices.

U.S. Food and Drug Administration (FDA)

Medical Coverage Policy: 0343 Non-powered patient lifts, seat lift mechanisms and standers are Class I devices and subject to the lowest level of regulatory control by the FDA. These types of devices present minimal potential harm to the user and are simple in design. Powered patient lifts are Class II devices.

Use Outside of the US

In a 2017 guideline on the assessment and management of cerebral palsy in persons under 25, the United Kingdom’s National Institute for Health and Care Excellence (NICE) advised practitioners not to offer standing frames solely to prevent low bone mineral density.