CurrentAetnaPolicy 0481

Tables and Boards (DME)

Defines Aetna's coverage, limitations, and exclusions for durable medical equipment tables and boards (e.g., postural drainage boards, prone boards, standers, tilt tables, transfer boards) for members when used for specified medical indications.

Policy Summary

PayerAetna

PolicyTables and Boards (DME)

Policy CodePolicy 0481

Change TypeNo material change

Effective DateJun 29, 2001

Next Review DateMay 9, 2024

Key ActionObtain prior authorization when billing the listed HCPCS codes for rental or purchase and ensure documentation meets the selection criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6Medically necessary items

7Excluded / noncovered items

6HCPCS codes covered

MultipleICD-10 groups

Covered Tables and Boards — Criteria

Medically Necessary Items

Aetna considers rental or, if less costly, purchase of the following tables and boards medically necessary when used for the specified indications.

Postural drainage boards: For members with chronic pulmonary conditions.

Prone boards: For members with neuromuscular conditions such as cerebral palsy or quadriplegia who need a prone board to assist them in being placed in an upright position.

Stand Aid/Stand Alone: To improve lower body strength for members with paraplegia and other neuromuscular conditions who are unable to rise from a seated to standing position without assistance and have some residual strength in the hips or legs such that they can maintain the standing position. Not medically necessary for members with complete paralysis of the hips and legs.

Policy Summary

PayerAetna

PolicyTables and Boards (DME)

Policy CodePolicy 0481

Change TypeNo material change

Effective DateJun 29, 2001

Next Review DateMay 9, 2024

Key ActionObtain prior authorization when billing the listed HCPCS codes for rental or purchase and ensure documentation meets the selection criteria.

SourceLink

On This Page

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Aetna considers rental, or if less costly, purchase of the following tables and boards medically necessary when used for the specified indications: postural drainage boards (for members with chronic pulmonary conditions); prone boards (e.g., Prone Board Standing System, Rifton Supine Board for members with neuromuscular conditions such as cerebral palsy or quadriplegia who need prone positioning to assist being placed upright); Stand Aid/Stand Alone (to improve lower body strength for members with paraplegia and other neuromuscular conditions who cannot rise from seated to standing without assistance but have some residual hip/leg strength to maintain standing); standers, standard nonpowered (for members with spastic quadriplegia and other neuromuscular conditions who have impaired ability to stand but can maintain standing due to residual lower body strength); tilt tables (for reconditioning of persons with orthostatic hypotension due to causes such as stroke, spinal cord injury, prolonged immobilization, or advanced age); and transfer boards (for members with medical conditions that limit transfers between wheelchair and bed, chair, toilet, etc.).

Medical Necessity Decision Logic

DME Medical Necessity Criteria — Tables and Boards

Postural drainage board criteria: Member has a chronic pulmonary condition warranting postural drainage.

Prone board criteria: Member has a neuromuscular condition (e.g., cerebral palsy, quadriplegia) and requires prone positioning to assist being placed in an upright position.

Stand Aid/Stand Alone criteria: Member cannot rise from seated to standing without assistance but has residual hip/leg strength to maintain standing; not for members with complete paralysis of the hips and legs.

Stander criteria (standard nonpowered): Member has impaired ability to stand but can maintain standing due to residual lower body strength; standers are not considered to offer clinically significant benefit for members with complete paralysis or those unable to maintain standing. Standers have no proven value for prevention or treatment of contractures.

Tilt table criteria: Used for reconditioning of persons with orthostatic hypotension (for example, due to stroke, spinal cord injury, prolonged immobilization, or advanced age). Because tilt-table use carries risk of syncope, home use requires arrangements for appropriate attendant supervision.

Transfer board criteria: Member has a medical condition that limits ability to transfer between wheelchair and bed, chair, toilet, or similar surfaces.

HCPCS and ICD-10 Codes

HCPCS codes covered if selection criteria are metHCPCSCovered

E0606	Postural drainage board
E0637	Combination sit to stand system, any size including pediatric, with seat lift feature, with or without wheels
E0638	Standing frame system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels
E0641	Standing frame system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels
E0642	Standing frame system, mobile (dynamic stander), any size including pediatric
E0705	Transfer device, any type, each

HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered

A9300	Exercise equipment
E0274	Over-bed table
E0315	Bed accessory: board, table, or support device, any type

ICD-10 codes covered if selection criteria are metICD-10

G70.00 - G70.9	Myasthenia gravis and other myoneural disorders
G73.3	Myasthenic syndromes in diseases classified elsewhere
G80.0 - G80.9	Cerebral palsy
G82.20 - G82.54	Paraplegia (paraparesis) and quadriplegia (quadriparesis)
I69.098, I69.198, I69.298, I69.398, I69.898, I69.998	Other sequelae of cerebrovascular disease
I95.1	Orthostatic hypotension
J40 - J47.9, J67.0 - J67.9	Chronic lower respiratory diseases and other lung diseases due to external agents
S14.0xxS - S14.159S, S24.101S - S24.159S	Injury of nerves and spinal cord, sequela (selected ranges)
S34.01xS - S34.139S	Injury of nerves and spinal cord, sequela (additional ranges)

ICD-10 codes not covered for indications listed in the CPB (for standers)ICD-10Not Covered

M24.50 - M24.9	Contracture of joint
M62.40 - M62.49, M62.830 - M62.838	Contracture of muscle [spasm]

Prior Authorization and Documentation Requirements

Prior Authorization

Prior Authorization Required for Specific HCPCS

Prior authorization is required for rental or purchase of specific HCPCS codes when the selection criteria in this policy are met. Submit prior authorization requests with supporting clinical documentation demonstrating the member meets the medical necessity criteria for the requested item.

Prior authorization required when requesting coverage for the HCPCS codes listed as covered in this policy.
Include clinical documentation of the underlying diagnosis, functional limitations, prior conservative therapy, and rationale for the specific device.
Rental vs purchase determination will follow contract terms and medical necessity; prior auth should indicate requested modality (rental or purchase).

Denial Risk

Coverage Denial Triggers

Items that do not meet Aetna’s contractual definition of covered durable medical equipment (DME) will be denied. Common denial triggers for tables and boards include: non-medical use, primarily for convenience or activities of daily living without a treating diagnosis that requires the device; devices classified as exercise equipment; and equipment intended for institutional use only.

Bed boards, cutout tables, foot boards, lapboards, over‑the‑bed tables (E0274), and standing tables are not covered.
Devices classified as exercise equipment (A9300) or stimulation/foot inversion boards are not covered.
Items considered institutional equipment (for example, Performa Power Mat Platform and transfer discs) are not appropriate for home use and will be denied.

Documentation Required

Home Use Supervision for Tilt Table

If a tilt table is prescribed for home use, the ordering provider must document arrangements for appropriate supervision. Supervision should be by an attendant (for example, a nurse, home health aide, or trained family member) who will oversee use and manage risks such as orthostatic intolerance and syncope.

Document the plan for attendant supervision in the medical record and include it with the prior authorization request if the tilt table is requested for home use.
Include training documentation for the attendant when available, and a plan for monitoring and emergency response during use.

Billing Rule

Provider/Billing Actions and Additional Notes

Providers should confirm member benefits and contract terms before submitting claims. Items lacking adequate documentation of medical necessity, items excluded by the member’s benefit plan, or items billed with incorrect HCPCS will be subject to denial or recoupment.

Verify benefit plan coverage for DME and exercise equipment exclusions prior to ordering.
Provide complete documentation with claims: diagnosis codes, clinical rationale, prior conservative treatments, and supplier notes.
Ensure correct HCPCS coding for the device requested; unsupported or miscoded requests may be denied.

Rental vs Purchase Guidance

Equipment	Rental \| Purchase Rule
{"text":"Postural drainage boards","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table when used for members with chronic pulmonary conditions.","status":""}
{"text":"Prone boards (e.g., Prone Board Standing System, Rifton Supine Board)","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table when used for members with neuromuscular conditions (e.g., cerebral palsy, quadriplegia) who need prone positioning to be placed upright.","status":""}
{"text":"Stand Aid/Stand Alone","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed device to improve lower body strength for members who cannot rise from seated to standing without assistance and have residual hip/leg strength to maintain standing; not medically necessary for members with complete paralysis of the hips and legs.","status":""}
{"text":"Standers, standard nonpowered","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed equipment for members with spastic quadriplegia and other neuromuscular conditions who can maintain standing due to residual strength; not for those with complete paralysis or unable to maintain standing; no proven value for prevention/treatment of contractures.","status":""}
{"text":"Tilt tables","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table for reconditioning of persons with orthostatic hypotension (e.g., due to stroke, spinal cord injury, prolonged immobilization, or advanced age).","status":""}

Key Definitions

Tilt table — definition and clinical purpose

DefinitionA tilt table is a table that tilts from a nearly horizontal to a vertical position.

Primary clinical purposeUsed for reconditioning persons with orthostatic hypotension (e.g., due to stroke, spinal cord injury, prolonged immobilization, or advanced age).

Reconditioning methodPatients are reconditioned to standing by gradually increasing tilt angle and duration from day to day.

Safety considerationSignificant risk of loss of consciousness (syncope) if angle of inclination or duration is excessive; use requires supervision.

Place of useGenerally used in facility settings by physical therapists; some models are for home use with appropriate attendant supervision.

Stand Aid / Stand Alone — device definition and intended use

DefinitionStand Aid/Stand Alone: a device to improve lower body strength for members who are unable to rise from a seated to standing position without assistance but have some residual hip/leg strength to maintain standing.

Intended usePermits the member to achieve and maintain a standing position to increase or maintain lower body strength.

Limitation - complete paralysisNot considered medically necessary for members with complete paralysis of the hips and legs where maintaining the standing position does not improve lower body strength.

Evidence noteStand Aids/Stand Alone have not been proven to offer clinically significant benefits for members with complete paralysis due to insufficient peer‑reviewed evidence.

Excluded Items and Noncovered Uses

The following tables and boards are not covered because they do not meet Aetna’s contractual definition of covered DME (not primarily medical in nature, not mainly used in treatment, or normally used by persons without disease/injury): bed boards (board inserted between bed spring and mattress), cutout tables (table cutout for use with wheelchair or prone board), foot boards (board at the end of the bed), lapboards (board used on the lap as a table or desk), and over-the-bed tables (overbed tables, e.g., Able Table). Also excluded as institutional equipment or non-home use are the Performa Power Mat Platform and transfer discs. In addition, most plans exclude exercise equipment such as foot inversion boards and stimulation boards — check individual benefit plan descriptions.

Background and Clinical Context

A tilt table is a table that tilts from a nearly horizontal to a vertical position and is primarily used for reconditioning persons with orthostatic hypotension due to causes such as stroke, spinal cord injury, prolonged immobilization, or advanced age. Reconditioning typically involves gradually increasing the tilt angle and duration. Because improper use carries a significant risk of syncope, tilt tables are generally used in facility settings by physical therapists, although some models may be used at home with documented arrangements for an appropriate supervising attendant.

Equipment	Rental \| Purchase Rule
{"text":"Postural drainage boards","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table when used for members with chronic pulmonary conditions.","status":""}
{"text":"Prone boards (e.g., Prone Board Standing System, Rifton Supine Board)","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table when used for members with neuromuscular conditions (e.g., cerebral palsy, quadriplegia) who need prone positioning to be placed upright.","status":""}
{"text":"Stand Aid/Stand Alone","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed device to improve lower body strength for members who cannot rise from seated to standing without assistance and have residual hip/leg strength to maintain standing; not medically necessary for members with complete paralysis of the hips and legs.","status":""}
{"text":"Standers, standard nonpowered","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed equipment for members with spastic quadriplegia and other neuromuscular conditions who can maintain standing due to residual strength; not for those with complete paralysis or unable to maintain standing; no proven value for prevention/treatment of contractures.","status":""}
{"text":"Tilt tables","status":""}\|{"text":"Aetna considers rental, or if less costly, purchase, of this listed table for reconditioning of persons with orthostatic hypotension (e.g., due to stroke, spinal cord injury, prolonged immobilization, or advanced age).","status":""}