Ambulatory Assist Devices: Walkers, Canes, and Crutches
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Defines Aetna's medical necessity, coverage, and exclusions for ambulatory assist devices including canes, crutches, various walkers, pediatric gait trainers and standers, and certain accessories; applies to Aetna members and their treating providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
COVERAGE CRITERIA — Canes and Crutches
Covered when ALL of the following are met
ALL of the following
- MRADL impairment: The member has a mobility limitation that significantly impairs ability to participate in one or more mobility-related activities of daily living (MRADL) in the home (toileting, feeding, dressing, grooming, bathing). A mobility limitation prevents accomplishing the MRADL entirely OR places the member at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL OR prevents completing the MRADL within a reasonable time frame.
- Safe use: The member is able to safely use the cane or crutch.
- Functional resolution: The functional mobility deficit can be sufficiently resolved by use of a cane or crutch.
ALL of the following
- Noncovered types note: Axillary (under-arm), articulated, spring-assisted crutches and sit-and-stand walking assistant crutches are not considered medically necessary because their clinical value has not been established.
ALL of the following
- Coding note: Canes or crutches that contain a spring that reduces impact and vibration should be coded with the existing codes for canes or crutches.
COVERAGE CRITERIA — Standard Walkers
Covered when ALL of the following are met
ALL of the following
- MRADL impairment: The member has a mobility limitation that significantly impairs ability to participate in one or more mobility-related activities of daily living (MRADL) in the home. A mobility limitation prevents accomplishing the MRADL entirely OR places the member at reasonably determined heightened risk of morbidity or mortality secondary to attempts to perform an MRADL OR prevents completing the MRADL within a reasonable time frame.
- Safe use: The member is able to safely use the walker.
- Functional resolution: The functional mobility deficit can be sufficiently resolved with use of a walker.
ALL of the following
- Walker types: A standard walker may be rigid or folding, may include 2, 3, or 4 wheels (fixed or swivel), may be fixed or adjustable height, and may include glide-type brakes or equivalent.
COVERAGE CRITERIA — Heavy-Duty Walker
Covered when ALL of the standard walker criteria are met AND the weight requirement is satisfied
ALL of the following
- Standard walker criteria: Member meets medical necessity criteria for a standard walker (see standard walker coverage criteria).
- Weight: Member weighs more than 300 pounds and requires a walker labeled as capable of supporting >300 lb.
ALL of the following
- Device features note: A heavy-duty walker may be fixed or adjustable height and may be rigid or folding; it may include wheels and glide-type brakes (glide-type brake = spring mechanism or equivalent).
ALL of the following
- Documentation requirement: Medical record should document member weight to justify heavy-duty walker selection.
COVERAGE CRITERIA — Heavy-Duty, Multiple Braking System, Variable Wheel Resistance Walker
Covered when ALL of the standard walker criteria are met AND additional functional limitation applies
ALL of the following
- Standard walker criteria: Member meets medical necessity criteria for a standard walker (see standard walker coverage criteria).
- Unable to use standard walker: Member is unable to use a standard walker due to a severe neurological disorder or other condition causing restricted use of one hand (obesity alone is not sufficient).
- Device characteristics: Device must meet enumerated technical specifications: at least 2 wheels with independently adjustable brakes that provide variable resistance; capacity to support >350 lb; hand-operated lockable brakes that can lock either or both wheels; individually adjustable brake pressure; and an additional braking mechanism on the front crossbar.
ALL of the following
- Exclusion note: Obesity alone is not considered a medically necessary indication for the heavy-duty, multiple braking system walker.
ALL of the following
- Documentation requirement: Medical record should justify the restricted one-hand use or severe neurologic impairment and include weight when requesting this specialized walker.
COVERAGE CRITERIA — Kneeling/Knee Walkers and Kneeling Crutches
Covered when ALL of the following are met
ALL of the following
- Standard device criteria: Member meets criteria for a standard walker, crutch, or cane.
- Unable to use standard devices: Member is unable to use a standard walker, crutch, or cane due to other impairments (e.g., only one functional arm) such that a kneeling walker/knee walker or kneeling crutch is required.
- Indication: Device is for below-the-knee injuries/conditions where the kneeling device provides the necessary functional support.
ALL of the following
- Examples include Roll-A-Bout (Rolleraid), Rolleraid, Turning Leg Caddy, and kneeling crutch devices such as iWALKFree.
ALL of the following
- Documentation requirement: Medical record should document inability to use standard devices and clinical justification for a kneeling device.
COVERAGE CRITERIA — Pediatric Crawlers, Gait Trainers and Standers
Covered when ALL of the following are met
ALL of the following
- Pediatric condition: Device is for a disabled child with impaired ambulation, lack of trunk stability and balance, cerebral palsy, or other severe neuromuscular conditions requiring moderate to maximum support.
- Device-specific: Device is an accepted pediatric device such as Mulholland Walkabout, Rifton/Pacer gait trainers, KidWalk, or the Therapeutic Ambulatory Orthotic System (TAOS) and is used for children who require the device's level of postural support and are capable of walking with it.
- Standers: Prone, supine and upright (including mobile/dynamic) standers for children with special needs (e.g., Rifton supine/prone/dynamic; Squiggles) are covered when medical necessity criteria are met and documentation supports the special features.
ALL of the following
- Exclusion note: Standard strollers are not covered. Specially adapted strollers may be considered medically necessary when used in place of a wheelchair for children and documentation supports this use.
ALL of the following
- Documentation requirement: Medical record should document the child's diagnosis, functional limitations, and justification that the selected pediatric device meets the child's support and mobility needs.
Aetna excludes certain device types and convenience accessories from coverage. Devices not considered medically necessary or not covered include axillary (under‑arm), articulated, spring‑assisted crutches and sit‑and‑stand walking assistant crutches (Upsee) because their clinical value or durability has not been established. Walkers with enclosed frames (a four‑sided framed, folding wheeled walker with a posterior seat) are not covered. Enhancement accessories — for example, style/color items, cup holders, baskets, seat or tray attachments — are considered convenience items and are not covered. Leg extensions are provided only for members who are 6 feet tall or more, and walking belts are not covered because they do not meet Aetna’s contractual definition of DME.
The Upsee mobility device is listed as experimental/investigational and not covered for certain neurodevelopmental indications. The policy specifically notes that the Upsee — a harness system composed of an adult hip belt, supportive child harness and shared sandals that enables a child to stand and walk with adult assistance — has a lack of evidence to support its use for individuals with Cri‑du‑chat syndrome. As a result, use of the Upsee for Cri‑du‑chat (and similar neurodevelopmental disorders listed) is unsupported by evidence and is not covered.
The following devices are specifically identified as not medically necessary or not covered: axillary (under‑arm), articulated, spring‑assisted crutches and sit‑and‑stand walking assistant crutches because their clinical value has not been established; walkers with enclosed frames (four‑sided framed walkers with posterior seat); and walking belts which do not meet the contractual definition of DME. Additionally, enhancement accessories (e.g., style/color items, cup holders, baskets, seat or tray attachments) are excluded as convenience items. These exclusions align with Medicare policy references cited in the document.
Medical Necessity Requirements
inv-31: MEDICAL NECESSITY — General DME medical necessity requirements for ambulatory assist devices
General DME medical necessity requirements for ambulatory assist devices
ALL of the following
- MRADL impairment: Significant impairment in one or more MRADLs in the home (toileting, feeding, dressing, grooming, bathing).
- Safe use: Member is able to safely use the ambulatory assist device being requested (cane, crutch, walker, or pediatric gait/standing device).
- Therapeutic effect: The functional mobility deficit can be sufficiently resolved by use of the device.
Not covered device types
- Enclosed-frame walkers: Walkers with enclosed frames (four-sided framed walkers with posterior seat) are not covered.
- Axillary/articulating spring-assisted crutches: Axillary (under-arm), articulated, spring-assisted crutches are not considered medically necessary.
- Sit-and-stand walking assistant crutches (Upsee): The Upsee mobility device is considered experimental/investigational and is not covered for indicated pediatric neurodevelopmental conditions.
Coding
| A4635 | Underarm pad, crutch, replacement, each. |
| A4636 | Replacement, handgrip, cane, crutch, or walker, each. |
| A4637 | Replacement, tip, cane, crutch, or walker, each. |
| E0100 | Cane, includes canes of all materials, adjustable or fixed, with tip. |
| E0105 | Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips. |
| E0110 | Crutches, forearm, includes crutches of various materials, adjustable of fixed, pair, complete with tips and handgrips. |
| E0111 | Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrip. |
| E0112 | Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips and handgrips. |
| E0113 | Crutch, underarm, wood, adjustable or fixed, each, with pad, tip and handgrip. |
| E0114 | Crutches, underarm, other than wood, adjustable or fixed, pair, with pads, tips and handgrips. |
| G11.0 - G11.9 | Hereditary ataxia |
| G12.0 - G12.9 | Spinal muscular atrophy and related syndromes |
| G13.0 - G13.8 | Systemic atrophies primarily affecting central nervous system in diseases classified elsewhere |
| G14 | Postpolio syndrome |
| G24.1 | Genetic torsion dystonia |
| G31.9 | Degenerative disease of nervous system, unspecified |
| G71.00 - G71.09 | Muscular dystrophy |
| G80.0 - G80.9 | Cerebral palsy |
| G81.00 - G82.54 | Hemiplegia, paraplegia and quadriplegia |
| Q05.0 - Q05.9 | Spina bifida |
| No codes listed |
Provider Actions & Requirements
Obtain prior authorization for covered HCPCS codes
Prior authorization is required when submitting claims for covered HCPCS codes; coverage is contingent on meeting the policy's medical necessity criteria for the requested device.
- Prior authorization applies to the listed covered HCPCS codes (e.g., E0130, E0135, E0147, E0148, E0149, E8000–E8002, A4635–A4637, etc.).
- Approval depends on documentation that all medical necessity criteria are met (MRADL impairment, ability to safely use the device, and that the device will resolve the functional deficit).
Apply Appendix billing and allowance rules
Follow the appendix allowance rules: items listed in Column II are included in the allowance for the corresponding Column I walker item and should not be billed separately when provided together.
- Confirm appropriate HCPCS coding and avoid separate billing for included accessories (replacement handgrips, tips, etc.).
- When accessories are provided concurrently with the primary walker, document concurrence to support bundled allowance.
No step therapy — meet medical necessity criteria
No step therapy process is specified in this policy; coverage requires that the member meet the medical necessity criteria listed in the policy before authorization.
- Requests should demonstrate MRADL impairment, safe use, and that the device will sufficiently resolve the functional mobility deficit.
Complete required provider actions before billing
Ensure all required provider actions are completed before claim submission: obtain prior authorization (when applicable), apply correct HCPCS codes, and document medical necessity and any device‑specific justifications.
- Use covered HCPCS codes listed in the policy for the requested device.
- Do not bill Column II items separately when provided with the primary Column I walker item.
- Provide complete clinical documentation to support medical necessity to avoid denials.
Include required clinical documentation in the medical record
Document in the medical record that the member has a mobility limitation significantly impairing one or more MRADLs in the home, that the member can safely use the device, and that the device will sufficiently resolve the functional mobility deficit.
- Specify which MRADLs are affected (toileting, feeding, dressing, grooming, bathing) and how the limitation meets the policy definition.
- Include clinical findings and assessments that support safe use and expected therapeutic benefit.
Document weight and justification for specialty walkers
For heavy‑duty or specialized walkers, include member weight and justification for special features (e.g., need for >300 lb capacity or >350 lb capacity with multiple braking system).
- Document actual member weight and why a heavy‑duty model is necessary.
- For heavy‑duty, multiple braking system walkers, document inability to use a standard walker (e.g., severe neurologic disorder or restricted use of one hand) and need for enumerated technical features.
Provide clinical evidence and rationale for novel devices
When requesting coverage for novel or less‑common devices (e.g., robotic gait trainers, Upsee, wearable FOG systems), include clinical evidence, rationale, and relevant outcome measures from the medical record or literature to support medical necessity.
- Cite pertinent studies or case reports and describe expected functional outcomes.
- Explain how the device aligns with the patient's functional goals and MRADL improvement.
Risk of denial for insufficient medical necessity documentation
Lack of documentation that all medical necessity criteria are met (MRADL impairment, ability to safely use device, and functional benefit) may result in denial of coverage.
- Absence of specific MRADL impairment details, safety assessment, or therapeutic rationale are common reasons for denial.
Do not bill for noncovered device types
Do not submit claims for devices the policy identifies as not covered (e.g., axillary/articulating spring‑assisted crutches, enclosed‑frame walkers, sit‑and‑stand walking assistant crutches/Upsee); such claims may be denied as not medically necessary or investigational.
Bundle Column II items with the primary walker allowance
When a Column II accessory is provided with the primary Column I walker at the same time, it is included in the allowance for the primary item and must not be billed separately.
- Document concurrent provision of accessories to support correct bundled billing.
- Separately billing included accessories may lead to denial or bundling adjustments.
Definitions
Rental & Purchase Rules
| Equipment category | Rental vs. purchase rule (policy text) | Notes / source |
|---|---|---|
| General ambulatory assist devices (canes, crutches, walkers, pediatric gait trainers, standers) | ||
| Policy references alignment with Medicare DME MAC Local Medical Policy; specific rental vs. purchase rules are not specified in the policy text provided. | ||
| See background statement: policy is based in part upon Medicare DME MAC Local Medical Policy (no explicit rental vs purchase rules in cited sections). |
| Column I (primary walker item) | Column II (items included in allowance when provided with Column I) | Billing implication / policy rule |
|---|---|---|
| Rigid (pick-up) walker, adjustable or fixed height (E0130) | ||
| Items listed in Column II for this walker (e.g., wheel attachments, brake attachments, replacement parts) — see appendix for specific items. | ||
| The item(s) in Column II are included in the allowance for the corresponding Column I walker when provided at the same time and must not be billed separately. |
Replacement Parts & Codes
Documentation Requirements
Clinical justification must document MRADL impairment, safety, and expected benefit
Document clinical justification in the medical record: MRADL impairment, ability to safely use the device, and that the device will sufficiently resolve the functional mobility deficit.
- For heavy‑duty or specialized walkers also include member weight and justification for special features.
Show concurrent accessory provision to support bundled billing
When accessories listed in Column II are provided concurrently with a primary walker, include documentation showing they were provided with the primary item to ensure correct bundled billing.
- Detail which accessories were provided and reference the corresponding primary walker code in the request/claim.
Not Covered / Exclusions
The following items are listed in the policy’s Not Covered/Exclusions: enclosed‑frame walkers (four‑sided framed walkers with an attached posterior seat), axillary/articulating spring‑assisted crutches, sit‑and‑stand walking assistant crutches (Upsee), and standard strollers. These items are excluded because their medical necessity or clinical value has not been established or they do not meet the contractual definition of DME.
Also excluded are enhancement accessories (e.g., seats, trays, baskets, cup holders) and devices categorized as experimental/investigational in the policy (for example, certain wearable freezing‑of‑gait systems and the Autoambulator).
The policy specifically notes that the Upsee mobility device is considered experimental/investigational for some neurodevelopmental disabilities and that there is insufficient evidence to support its use for Cri‑du‑chat syndrome. As a result, Upsee is not covered for this indication under the policy.
The Upsee is described in the background as a harness system composed of an adult hip belt, a child harness, and shared sandals that allows children with motor impairment to stand and ambulate with adult assistance, but the policy emphasizes the lack of supporting evidence for Cri‑du‑chat.
Background and Evidence
This policy references Medicare DME MAC local medical policy as a basis for coverage determinations for ambulatory assist devices and aligns with DME definitions when assessing device durability and clinical value. The background section notes the policy’s use of Medicare guidance in establishing coverage positions.
Clinical context supporting the policy includes discussion of assistive technologies for gait: robotic gait trainers (AutoAmbulator/robot‑assisted gait training) are reviewed in the literature with mixed evidence—systematic reviews report some balance improvements but limited high‑quality comparative outcomes—and therefore the AutoAmbulator is considered experimental/investigational.
The policy also references a feasibility study of a wearable freezing‑of‑gait detection system (deFOG) showing detection of FOG events and acoustic cueing to unfreeze gait; however, the policy concludes that evidence is insufficient to support routine use of wearable FOG detection systems for Parkinson’s disease, and these devices are listed as experimental/investigational.
Revision History
Policy effective date recorded.
Policy underwent review (last review date recorded).
Next review scheduled as recorded in policy metadata.
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