The Centers for Medicare & Medicaid Services (CMS) addresses numerous items that it terms “mobility assistive equipment” (MAE) and includes within that category canes and crutches.

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, " based on Social Security Act 1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage.

For an item to be covered, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

Canes (E0100, E0105) and crutches (E0110 - E0116) are covered if all of the following criteria (1-3) are met:

1. The patient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home.
   

   The MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.

   A mobility limitation is one that:

   1. Prevents the patient from accomplishing the MRADL entirely, or
   2. Places the patient at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
   3. Prevents the patient from completing the mobility-related activities of daily living within a reasonable time frame.
   
   and
   
   
2. The patient is able to safely use the cane or crutch; and
   
   
3. The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.

If all of the criteria are not met, the cane or crutch will be denied as not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

The medical necessity for an underarm, articulating, spring assisted crutch (E0117) has not been established; therefore, if an E0117 is ordered, it will be denied as not medically necessary.

Reasons for Noncoverage

A white cane for a blind person is noncovered since it is a “self help” item. A white cane for use by a blind person is more an identifying and self-help device rather than an item which makes a meaningful contribution in the treatment of an illness or injury. Code A9270 must be used for a white cane for a blind person. The provider cannot bill the member for the denied 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 billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.

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.

Code A9270 must be used for a white cane for a blind person.

All canes and crutches are billed using the specific codes listed in this policy regardless of their stated weight capacity. Do not use code E1399 (DME, miscellaneous) to code any type of cane or crutch regardless of special features or weight capacity.

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

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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, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.2, 280.3