Seat lift mechanisms are designed to assist patients to stand from a sitting position. Seat lifts can be built into chairs or can be separate for use with other furniture.

For any item to be covered, 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 statutory and regulatory requirements.

For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage.

For an item addressed in this policy to be covered, 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 non-covered. 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 met:

1. The patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease.
   
   
2. 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.
   
   
3. 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.)
   
   
4. 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.

Coverage is limited to the seat lift mechanism, even if it is incorporated into a chair (E0627). Payment for a seat lift mechanism incorporated into a chair (E0627) is based on the allowance for the least costly alternative (E0628, E0629).

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.

Reasons for Noncoverage

A seat lift mechanism placed over or on top of a toilet, any type (E0172) is non-covered. The provider can bill the member for the non-covered service.

Documentation Requirements

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items delivered before a signed written order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.

A Certificate of Medical Necessity (CMN), which has been completed, signed and dated by the treating physician, must be kept on file by the supplier, and made available upon request. The CMN may act as a substitute for a written order if it contains all of the required elements of an order. The initial claim must include an electronic copy of the CMN.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

When providing a seat lift mechanism which is incorporated into a chair as a complete unit at the time of purchase, suppliers must bill the item using the established procedure code, E0627. In this situation, the supplier may bill the seat lift mechanism using E0627 and A9270 for the chair. However, if the seat lift mechanism, electric or non-electric, is supplied as an individual unit to be incorporated into a chair that a patient owns, the supplier must bill using the appropriate code for the seat lift mechanism for use with patient owned furniture, E0628 or E0629.

A toilet seat lift mechanism (E0172) is a device with a seat that can be raised with or without a forward tilt while the patient is seated, allowing the patient to ambulate once he/she is in a more upright position. It may be manually operated or electric. It is attached to the toilet.(For information about seat lift mechanisms which are incorporated in a commode, see the Commodes policy, E-71.)

Effective September 1, 2009, suppliers should contact the Pricing, Data Analysis and Coding (PDAC) Contractor for guidance on the correct coding of these items. https://www.dmepdac.com/

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

CMS Pub. 100-3, Chapter 1, Section 280.4