CurrentCareSourcePolicy Special Needs Car Seats-AR PASSE-MM-1437

Special Needs Car Seats - Arkansas PASSE

Defines medical necessity, documentation, and coverage conditions for special needs car seats for members in the Arkansas PASSE program (CareSource). Applies to providers requesting coverage for special needs car seats.

Policy Summary

PayerCareSource

PolicySpecial Needs Car Seats - Arkansas PASSE coverage criteria

Policy CodePolicy Special Needs Car Seats-AR PASSE-MM-1437

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionSubmit a physician order, invoice, and person-centered service plan (PCSP) with the prior authorization request and bill under HCPCS code T2028.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

FMVSS No. 213applicable federal safety standard referenced

T2028required HCPCS billing code

05/01/2025policy effective date

physician orderdocumentation requirement

invoice + PCSPadditional documentation

Coverage Criteria

inv-01: Medical necessity general criteria

Covered when ALL of the following are met:

Primary coverage criteria: 1) The car seat is a restraint system that meets FMVSS No. 213; 2) The car restraint system is not modified or used other than manufacturer specifications unless the modified restraint system has been crash tested and meets applicable FMVSSs approved by NHTSA; 3) The safety and effectiveness of the special needs car seat is substantiated by current evidence-based national, state, or peer-reviewed medical guidelines; 4) The special needs car seat is the most cost-effective option that still addresses the member's medical/functional needs; 5) A physician order is provided; 6) An invoice for the equipment is provided; 7) A person-centered service plan (PCSP) is provided; 8) The member has outgrown the length or weight limits of a conventional CRS with an internal 5-point harness and at least one qualifying clinical condition is present (see qualifying clinical conditions).all

inv-02: Qualifying clinical conditions

At least one of the following clinical conditions must be present:

Qualifying clinical conditions:

Policy Summary

PayerCareSource

PolicySpecial Needs Car Seats - Arkansas PASSE coverage criteria

Policy CodePolicy Special Needs Car Seats-AR PASSE-MM-1437

Change TypeNo material change

Effective DateMay 1, 2025

Next Review Date

Key ActionSubmit a physician order, invoice, and person-centered service plan (PCSP) with the prior authorization request and bill under HCPCS code T2028.

SourceLink

On This Page

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a) Hypotonia, including respiratory issues or conditions that require enhanced positioning for safety; b) Craniofacial abnormalities; c) Cerebral palsy; d) Primary airway problems; e) A physical condition (e.g., seizure or hypertonicity/spasms) that prevents independent maintenance of a seated position or requires support to allow a functional position or prevent further disability; f) Emesis or other gastrointestinal issues; g) Gastroesophageal reflux (GERD); h) Spica cast; i) Gastrostomy feeding tube; j) Presence of a tracheostomy tube requires specialized guidance (persons with a tracheostomy should not use a CRS with a harness or seat belts that could dislodge the tube).

A special needs car seat will not be considered medically necessary if it is investigational, experimental, or has unproven medical indications for use. Providers should rely on evidence-based, nationally recognized clinical guidance and manufacturer safety information when proposing equipment; items lacking substantiated medical benefit do not meet coverage criteria.

A special needs car seat is not medically necessary when it represents only a newer technology or incremental advancement and the member’s existing special needs car seat already meets the member’s basic medical and functional needs. Coverage requires that the requested device provide a distinct, demonstrable medical or functional benefit beyond the current equipment.

Use of a child restraint system (CRS) with a harness or seat belts that could dislodge a tracheostomy tube is contraindicated. Persons with a tracheostomy should not use such CRS; it is strongly recommended that an occupational therapist or a passenger safety technician with appropriate training provide guidance on safe equipment selection and use for these members.

Medical Necessity for DME

inv-18: Special needs car seat DME criteria

DME medical necessity criteria mirror the clinical coverage criteria and manufacturer/safety requirements; coverage requires ALL of the following:

DME necessity: Equipment must meet FMVSS No. 213; not be modified or used other than manufacturer specifications unless crash-tested and compliant with applicable FMVSSs; safety and effectiveness supported by current evidence-based guidelines; the special needs car seat must be the most cost-effective option to meet the member's medical/functional needs; required documentation (physician order, invoice, and person-centered service plan) must be provided; member must have outgrown the length or weight limits of a conventional CRS with internal 5-point harness and have at least one qualifying clinical condition.all

Coding

Covered HCPCS CodesHCPCSCovered

T2028

Special needs car seat

Provider Actions & Billing

Prior Authorization

Special needs car seat PA and billing

Prior authorization and billing requirements apply for special needs car seats. Coverage requires submission of a physician order, an invoice for the equipment, and a person-centered service plan (PCSP). The item must be the most cost-effective option that still meets the member's medical/functional needs. Failure to bill using HCPCS code T2028 may result in noncompliance and claim denial. Coverage may be denied if any required documentation is missing.

Required documentation: physician order; invoice for the equipment; person-centered service plan (PCSP).
Cost-effectiveness: the special needs car seat must be the most cost-effective option that addresses the member's medical/functional needs.
Billing code: must be billed under HCPCS code T2028.
Missing documentation or incorrect billing may result in denial of coverage.

Required Documentation

Note

Submit physician order, invoice, and PCSP with request

Include a physician order, an invoice for the equipment, and a person-centered service plan (PCSP) when submitting the request for coverage.

Physician order
Invoice for the equipment
Person-centered service plan (PCSP)

Rental & Purchase Rules

Item	Rule / Notes	Billing Code
Special needs car seat	Policy specifies that a special needs car seat is covered when medical necessity criteria are met; required documentation includes a physician order, an invoice, and a person-centered service plan (PCSP). The policy does not state explicit rental versus purchase rules for special needs car seats.	T2028

Replacement

inv-20: Special needs car seat — replacement details

Replacement interval stated in policyNo explicit replacement interval is stated in the policy.

Documentation required for replacement requestPhysician order, invoice for equipment, and person-centered service plan (PCSP) must be submitted with the request.

Replacement decision basisReplacement considered when member outgrows length/weight limits of a conventional CRS with internal 5-point harness and qualifying clinical condition is present.

Definitions

inv-13: Booster Seat definition

DefinitionBooster Seat: A seat used for a child during transportation that lifts the child by several inches, designed for use with an adult seat belt.

Typical useUsed when child has outgrown a car safety seat but still requires elevation for proper adult seat belt fit.

Relation to FMVSS No. 213FMVSS No. 213 clarifies applicability to booster manufacturers; boosters may be subject to height/weight labeling requirements.

inv-14: Car Safety Seat (CSS) definition

DefinitionCar Safety Seat (CSS): A portable seat for a person weighing under 80 pounds that attaches to an automobile seat and holds the person safely.

Regulatory limitFMVSS No. 213 regulates child restraint systems up to 80 pounds.

Document updatesPolicy definitions for car seats were updated during the 02/28/2024 annual review.

inv-15: Travel Vest definition

DefinitionTravel Vest: Optimizes the existing vehicle seat belt system to protect the child by keeping a low center of gravity and allowing the vehicle seat belt and seat cushion to manage the crash forces.

PurposeProvides an alternative when conventional CRS designs do not meet the child’s positioning or safety needs.

Use considerationShould be used consistent with manufacturer instructions and FMVSS guidance.

inv-16: Neck Loading definition

DefinitionNeck Loading: The dynamic loading of the neck that occurs when the torso is suddenly stopped by the seat belt while the head continues pulling from the neck.

Clinical relevanceImportant consideration for members with poor head control or neurologic conditions when selecting restraint systems.

Contraindication implicationRestraint choices that increase neck loading (or place traction on a tracheostomy) may be contraindicated.

inv-17: FMVSS No. 213 definition

DefinitionFMVSS No. 213: Federal Motor Vehicle Safety Standard regulating design and performance of child restraint systems.

ScopeRequires child restraint systems (CRSs) to be equipped with attachments enabling attachment to the vehicle's restraint anchorage system.

Applicability noteStandard's applicability and labeling provisions clarify requirements for booster seat manufacturers (height/weight applicability).

Background

The American Academy of Pediatrics recommends appropriate restraints and positioning for safe transportation of children with functional needs. For some children standard car seats are sufficient; however, children with conditions such as poor trunk control, neurologic disorders, or other functional impairments may require specialized seating or travel vests to achieve a safe, functional position during transit. Selection and use of specialized restraint systems should follow manufacturer guidance and be informed by clinicians or trained passenger safety specialists.

Not Covered

Not covered: investigational or unproven special needs car seats; devices that are simply newer technology when the member’s current special needs car seat meets basic medical/functional needs; and CRS or harness systems that could dislodge a tracheostomy tube. For members with a tracheostomy, specialized assessment and guidance from an occupational therapist or passenger safety technician are strongly recommended.