Children's Mobility and Positioning Equipment
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Defines medical necessity, coverage, exclusions, documentation, and coding guidance for durable medical equipment used to provide mobility and positioning for children with chronic disabilities. Applies to providers and DME suppliers seeking coverage from Blue Cross Blue Shield of North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria for Mobility & Positioning Equipment
When covered
Covered when ALL of the following are met
All five numbered items must be satisfied.
The policy excludes items that do not serve a medical purpose or that are primarily for recreation, leisure, or non-medical transport. Specifically, adapted toys (for example, floor scooters, tricycles, or computer switch toys) and standard strollers are not considered durable medical equipment and are excluded. Equipment primarily intended for leisure, recreation, sports, sitting in a motorized vehicle, or provided solely to enable attendance at school is also excluded. Additionally, devices listed as convenience items (see exclusions) are not covered under most health benefit plans.
Items that are provided primarily for comfort, convenience, or recreational use do not meet the plan’s definition of durable medical equipment and are not covered. Examples include equipment that serves no medical purpose and convenience devices; suppliers and members should consult the Member’s Benefit Booklet for plan-specific exclusions.
Medical Necessity Requirements
DME medical necessity
Medical necessity requires meeting all of the following:
See Policy Guidelines for requirement to specify frequency, duration, and place of intended use.
Provider Responsibilities, Prior Authorization, and Evaluation
Prior authorization, medical necessity, and supplier eligibility
Coverage decisions require submission of documentation that demonstrates medical necessity. Approval is generally limited to one mobility device and one positioning device every 2 years; supplier must be acceptable to the Plan and meet Plan eligibility/credentialing requirements for reimbursement.
- Coverage requires documentation of medical necessity.
- Approval is generally limited to one mobility device and one positioning device every 2 years.
- DME supplier must be acceptable to the Plan and meet eligibility/credentialing requirements.
Conservative equipment alternatives required
Before specialized mobility or positioning equipment will be approved, the provider must document that manual wheelchairs and standard strollers cannot be adapted to safely meet the child’s positioning needs.
- Provider must show manual wheelchairs cannot be adapted to safely meet positioning needs.
- Provider must show standard strollers cannot be adapted to safely meet positioning needs.
Required clinical documentation for medical necessity
Submit detailed clinical documentation to support medical necessity including diagnosis, prognosis, functional deficits, and how the equipment will address those deficits.
- Child’s diagnosis and prognosis.
- The child’s specific functional disabilities that will be improved by the requested equipment.
- The child’s ability to appropriately and functionally use and benefit from the equipment.
- The functional goals for use of the equipment that relate to improved medical or functional status.
- The medical conditions expected to be prevented by use of the equipment and evidence the child is at risk (e.g., flexion contractures).
- BCBSNC may request medical records; letters of support are supplementary and insufficient unless all required information is provided.
Independent evaluation and usage details required
An independent evaluation must be completed by a specialized seating/mobility clinic or by a physician and therapist knowledgeable about prescribing mobility devices; documentation must specify frequency, duration, and place of intended use.
- Evaluation must be independent from the vendor supplying the equipment.
- Specify frequency, duration and place of intended use in the plan of care.
- Therapist must document rationale for selection of the specific product over available alternatives and evidence of documented successful use.
Noncovered uses and convenience items — denial risk
Requests for equipment primarily intended for leisure, recreation, sports, sitting in a motorized vehicle, sole purpose of attending school, or that are convenience items are considered noncovered and will be denied.
- Adapted toys (floor scooters, tricycles, computer switch toys) are not considered DME and are not covered.
- Standard strollers are not considered DME and are not covered.
- Convenience items (electric patient lifts, seat lift mechanisms, ceiling lifts, patient support mechanisms, standing frames) are not covered.
- Equipment primarily for leisure/recreation/sports, sitting in a motorized vehicle, or sole purpose of attending school will be considered noncovered.
Applicable HCPCS / K Codes
Documentation Requirements
Provide full clinical records on request; letters of support are supplementary
Submit complete clinical records as requested; BCBSNC may request medical records and letters of support are supplementary but are not sufficient by themselves unless they include all required information for medical necessity determination.
- Be prepared to provide medical records when requested by BCBSNC.
- Ensure letters of support include all specific required information if relied upon, otherwise include them only as supplementary documentation.
Documentation checklist — required clinical details (emphasis)
Reiterate: include the child’s diagnosis and prognosis; specific functional disabilities to be improved; the child’s ability to use and benefit from the equipment; functional goals; and conditions expected to be prevented with evidence of risk in all submissions.
- Diagnosis and prognosis
- Functional disabilities targeted
- Ability to use and benefit from equipment
- Functional goals tied to medical/functional improvement
- Conditions expected to be prevented and risk indicators
Rental and Purchase Rules
| Category | Rule / Requirement |
|---|---|
| General rule | Purchase (ownership) is the billing rule for general durable medical equipment under this policy; the DME supplier must be acceptable to the Plan and meet eligibility/credentialing requirements for reimbursement. |
| Frequency / Replacement | Approval is generally limited to one mobility device and one positioning device every 2 years; requests should indicate potential for growth or anticipated functional change can be reasonably accommodated for 2 years. |
| Documentation requirements | Approval determined based on documentation of medical necessity; required documentation includes child’s diagnosis and prognosis; specific functional disabilities to be improved; ability to appropriately and functionally use and benefit from the equipment; functional goals related to improved medical or functional status; and medical conditions expected to be prevented and evidence the child is at risk. BCBSNC may request medical records; letters of support are supplementary and not sufficient alone unless they contain all required information. |
| Place / Use specification | Frequency, duration and place of intended use must be specified in the documentation. |
Replacement Frequency
Key Definitions
Items and Services Not Covered
Not covered under this policy are standing frames (listed as a benefit exclusion), adapted toys, and standard strollers. The policy also considers certain convenience items to be noncovered, including examples such as electric patient lifts, seat lift mechanisms, ceiling lifts, and other patient support mechanisms. Requests for these items will be denied because they are classified as convenience or non-medical equipment.
Noncovered purposes and convenience items — denial risk
Requests primarily for leisure, recreation, sports, sitting in a motorized vehicle, sole purpose of attending school, or for convenience items (e.g., electric patient lifts, seat lift mechanisms, ceiling lifts, patient support mechanisms, standing frames) are noncovered and will result in denial if submitted as medical necessity.
- Do not bill or request coverage for adapted toys, standard strollers, or convenience items as DME.
- Document primary medical purpose clearly to avoid denials related to noncovered use.
Background and Scope
Children with chronic disabilities (for example, cerebral palsy or spina bifida) may require adaptive mobility and positioning equipment to assist with activities of daily living, support posture, and help prevent secondary medical complications. Selection of mobility and positioning devices should be driven by a clinical evaluation and clearly defined functional goals rather than by leisure or convenience considerations. An independent evaluation by a specialized seating/mobility clinic or by clinicians knowledgeable about prescribing mobility devices is required to document medical necessity.
Policy Revision History
Policy originated (Origination).
Original policy issued (implementation record).
Revised to add DME supplier information and source as contract language.
Reaffirmed by the Medical Policy Advisory Group.
Reformatted and medical term definitions added.
System coding changes implemented.
Specialty Matched Consultant Advisory Panel review; no change recommended to criteria.
Strollers added to 'when it is not covered' section.
Revised 'when it is not covered' to state strollers are not medically necessary and considered noncovered.
Added detailed medical necessity criteria to 'When Children’s Mobility and Positioning Equipment is Covered' and updated noncovered items and HCPCS codes.
Updated covered and not-covered lists (converted to numbered lists), added requirement for frequency/duration/place of use, and added Item 5 about documented successful use and therapist rationale.
Policy number(s) removed.
Specialty Matched Consultant Advisory Panel review.
Added medical necessity criteria to 'When Covered' section (implementation/update record).
Added HCPCS code E0638; standing frames noted as benefit exclusion.
Revised 'When Not Covered' wording to clarify items are not considered DME and removed standing frames reference as it became a standard benefit exclusion.
Deleted HCPCS code E1340 from Billing/Coding section.
Added the word 'safely' to statement #2 under 'When Covered'.
Editorial change in Description section relocating the word 'prone' in stander examples.
Specialty Matched Consultant Advisory Panel review; no change to policy statement.
Specialty Matched Consultant Advisory Panel and Medical Director reviews; policy intent unchanged.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
Specialty Matched Consultant Advisory Panel and Medical Director reviews.
References updated; Specialty Matched Consultant Advisory Panel and Medical Director reviews in 9/2022.
References updated; Specialty Matched Consultant Advisory Panel and Medical Director reviews in 9/2023.
References updated; Specialty Matched Consultant Advisory Panel and Medical Director reviews in 9/2024.
Added a note in Description section stating the medical policy is complex and technical; references updated with Specialty Matched Consultant Advisory Panel and Medical Director reviews in 9/2025.
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