CurrentCentenePolicy CP MP.99

Wheelchair Seating - Coverage Criteria and Medical Necessity

Defines medical necessity, coding, and exclusions for wheelchair seat cushions, back cushions, positioning accessories, and related components for members of Centene-affiliated health plans.

Policy Summary

PayerCentene

PolicyWheelchair Seating - Coverage Criteria and Medical Necessity

Policy CodePolicy CP MP.99

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionInclude a supporting ICD-10-CM diagnosis from the policy list with prior authorization or claim documentation to substantiate medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CP MP.99Centene clinical policy reference

12HCPCS codes supported (excerpt)

E0992/E2610/K0669Not medically necessary codes

~30+ICD-10 diagnosis codes listed

Coverage Criteria

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General use cushions: A general use seat cushion (E2601, E2602) and a general use wheelchair back cushion (E2611, E2612) provided for an approved manual wheelchair or power wheelchair with a sling or solid seat/back.

See policy criteria for approved wheelchair types.

Skin-protection seat cushion - coverage: A skin-protection seat cushion (E2603, E2604, E2622, E2623) when used with an approved manual wheelchair or power wheelchair with a sling or solid seat/back AND at least ONE of the following: (1) current pressure ulcer on the area of contact or past history of a pressure ulcer on the area of contact; OR (2) absent or impaired sensation in the contact area; OR (3) inability to carry out functional weight shifts due to one of the listed neurologic diagnoses.

Neurologic and pressure-ulcer diagnosis lists in the ICD-10 section support medical necessity (see diagnosis tables).

Positioning cushions and accessories: A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) when there are significant postural asymmetries due to one of the enumerated diagnoses AND the member has an approved manual or power wheelchair with a sling or solid seat/back.

See ICD-10 diagnosis tables for conditions that substantiate significant postural asymmetry.

Headrest: A headrest (E0955) when the member has an approved manual tilt-in-space wheelchair, manual semi- or fully-reclining back on a manual wheelchair; a manual fully reclining back on a power wheelchair; or power tilt and/or recline power seating system.

Headrest coverage tied to specified wheelchair seating/back configurations.

Combination cushions: A combination skin-protection and positioning seat cushion (E2607, E2608, E2624, E2625) when the member meets the criteria for both skin-protection and positioning cushions as described above.

Combination codes require meeting both component criteria.

inv-02: Custom Fabricated Seating

Custom fabrication covered when ALL of the following are met

Custom seat cushion (E2609): Custom fabricated seat cushion (E2609) is covered when the member meets all criteria for a prefabricated skin-protection or positioning seat cushion AND there is a comprehensive written evaluation by a licensed/certified physical therapist or occupational therapist that clearly explains why prefabricated seating is insufficient to meet seating and positioning needs.

The evaluating PT/OT must have no financial relationship with the supplier; documentation must be maintained in the medical record.

Custom back cushion (E2617): Custom fabricated back cushion (E2617) is covered when the member meets all criteria for a prefabricated positioning back cushion AND there is a comprehensive written evaluation by a licensed/certified physical therapist or occupational therapist that clearly explains why prefabricated seating is insufficient to meet seating and positioning needs.

The evaluating PT/OT must have no financial relationship with the supplier; include detailed justifying evaluation.

inv-03: Not Medically Necessary / Exclusions

Not medically necessary when ANY of the following apply

Captain's chair exclusions: Separate seat cushion, back cushion, headrest, and/or other positioning accessories are not medically necessary when the member has a power-operated vehicle (POV) or power wheelchair with a captain's chair seat.

Power wheelchair bases without captain's chair models are referenced in the policy (K0839, K0840, K0843).

General cushion with captain's chair: A general use seat cushion (E2601, E2602) is not medically necessary if the member has a POV or power wheelchair with a captain's chair seat.

Transport chair exclusion: Seat or back cushions provided for use with a transport chair (E1037, E1038) are not medically necessary.

Powered seat cushion (E2610) is not medically necessary for any indication because effectiveness has not been established.

E2610 is listed as not medically necessary in the policy.

Coding

Seat Cushions (HCPCS)HCPCS

E2601	General use wheelchair seat cushion, width less than 22 inches, any depth
E2602	General use wheelchair seat cushion, width 22 inches or greater, any depth
E2603
E2604
E2605	Positioning wheelchair seat cushion, width less than 22 inches, any depth
E2606	Positioning wheelchair seat cushion, width 22 inches or greater, any depth
E2607	Skin protection and positioning wheelchair seat cushion, width less than 22 inches, any depth
E2608	Skin protection and positioning wheelchair seat cushion, width 22 inches or greater, any depth
E2609	Custom fabricated wheelchair seat cushion, any size
E2622	Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth

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Positioning Accessories (HCPCS)HCPCS

E0953	Wheelchair accessory, lateral thigh or knee support; any type including fixed mounting hardware, each
E0955	Wheelchair accessory, headrest; cushioned, any type, including fixed mounting hardware, each
E0956	Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each
E0957	Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each
E0960	Wheelchair accessory, shoulder harness/straps or chest including any type mounting hardware, each
E0966	Manual wheelchair accessory, headrest extension, each
E1028	Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick or other control interface or positioning accessory

Miscellaneous (HCPCS)HCPCS

A9900	Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
E2231	Manual wheelchair accessory, solid seat support base (replaces seat), includes mounting hardware
E2292	Seat, planar, for pediatric size wheelchair including fixed attaching hardware
E2293	Back, contoured for pediatric size wheelchair including fixed attaching hardware
E2294	Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E2619	Replacement cover for wheelchair seat cushion or back cushion, each
K0108	Wheelchair component or accessory not otherwise specified
E229]

Not Medically Necessary (HCPCS)HCPCSNot Covered

E0992	Manual wheelchair accessory solid seat insert (not medically necessary)
E2610	Wheelchair seat cushion, powered (not medically necessary)
K0669	Wheelchair accessory, seat or back cushion, does not meet specific code criteria or no written coding verification from DME PDAC (not medically necessary)

HCPCS Codes with Supporting DiagnosesmixedCovered

E0953	Supported when billed with listed diagnosis codes
E0956	Supported when billed with listed diagnosis codes
E0957	Supported when billed with listed diagnosis codes
E0960	Supported when billed with listed diagnosis codes
E2605	Supported when billed with listed diagnosis codes
E2606	Supported when billed with listed diagnosis codes
E2613	Supported when billed with listed diagnosis codes
E2614	Supported when billed with listed diagnosis codes
E2615	Supported when billed with listed diagnosis codes
E2616	Supported when billed with listed diagnosis codes

1–10 of 13

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ICD-10 Codes That Support Medical Necessity (excerpt)ICD-10Covered

G81.90	Hemiplegia, unspecified affecting unspecified side
Z89.621	Acquired absence of right hip joint
Z89.622	Acquired absence of left hip joint
Q72.02	Congenital complete absence of left lower limb

Provider Actions / Authorization & Billing

Prior Authorization

Diagnosis-supported Prior Authorization

Prior authorization (PA) is required and will be approved only when the requested HCPCS code is supported by the applicable ICD-10-CM diagnosis codes listed in this policy. For HCPCS codes E2607, E2608, E2624, E2625 and other specified pressure-relief seating codes, include a pressure-ulcer diagnosis from the listed ICD-10-CM codes when submitting a PA request.

Diagnosis-supported prior authorization: PA requests must include a supporting ICD-10-CM diagnosis from the "ICD-10-CM Diagnosis Codes That Support Medical Necessity" lists in this policy.
Diagnosis-code linkage for pressure-relief seating: When requesting HCPCS E2607, E2608, E2624, or E2625, bill the applicable pressure ulcer ICD-10-CM code with the HCPCS code to substantiate medical necessity.

Documentation Required

Documentation Required for Custom Fabrication

A comprehensive, written evaluation by a licensed/certified physical therapist (PT) or occupational therapist (OT) is required to justify custom fabrication (HCPCS E2609 for cushions, E2617 for backs). The evaluation must clearly explain why prefabricated options are insufficient to meet the member's seating and positioning needs and the evaluator must have no financial relationship with the supplier.

Documentation for custom fabrication: Include a detailed functional assessment, measurements, treatment goals, and explanation of why prefabricated cushions cannot meet clinical needs.
Prefabricated-first expectation: Providers should trial and document prefabricated solutions prior to requesting custom-fabricated items, unless contraindicated by clinical circumstance.

Denial Risk

Denial Triggers & Missing Diagnosis Risk

Certain HCPCS codes are designated Not Medically Necessary and will trigger denials unless an exception is documented per this policy or plan contract. Requests lacking a listed supporting diagnosis may also be denied.

Not Medically Necessary codes that may trigger denial: E0992, E2610, K0669.
Missing supporting diagnosis may trigger denial: PA requests or claims for listed HCPCS without an applicable ICD-10-CM diagnosis from this policy risk denial.
Required supporting diagnosis: Claims and medical records must include one of the ICD-10-CM diagnosis codes listed in the policy to support the specific HCPCS code requested.

Documentation Required

Documentation and Diagnosis Linking Requirements

Maintain documentation that links the beneficiary's diagnosis to the requested HCPCS code(s). For pressure-relief seating items (E2607, E2608, E2624, E2625) and for E2609 (custom-fabricated cushions), ensure the claim and supporting medical record include one of the ICD-10-CM codes listed for those codes in this policy.

Diagnosis documentation: Include the applicable ICD-10-CM code on the PA request and claim form and retain the clinical record showing the diagnosis, assessment, and rationale for the item.
Diagnosis requirement for E2609: PA/medical necessity review for E2609 requires an applicable ICD-10-CM diagnosis code from the policy's E2609 diagnosis list.
Diagnosis support requirement: For specified HCPCS (see policy lists), medical necessity must be supported by one of the listed ICD-10-CM diagnosis codes.

Note

Reference Documents and Plan-Level Coverage

Coverage decisions and prior authorization requirements are governed by the member's plan contract and the Health Plan's administrative policies. Providers should reference the primary source materials when preparing documentation and PA requests.

Reference documents: HCPCS Level II (2024), ICD-10-CM (2024), LCD L33312, and Local Coverage Article A52505 inform the clinical and documentation requirements in this policy.
Plan coverage conditional: Coverage is subject to the terms, exclusions, and limitations of the member's evidence of coverage or plan contract; prior authorization may be required per Health Plan rules.

Medical Necessity

inv-65: Equipment medical necessity

Medical necessity depends on cushion type — key required conditions include:

Skin protection criteria: Current or prior pressure ulcer on the area of contact OR absent or impaired sensation in the contact area OR inability to perform functional weight shifts due to one of the listed neurologic diagnoses.

Supported by ICD-10 codes listed in the policy (see ICD-10 sections).

Positioning criteria: Significant postural asymmetries due to listed diagnoses plus an approved manual or power wheelchair with a sling or solid seat/back.

See policy for examples of qualifying diagnoses and postural asymmetry requirements.

inv-66: DME medical necessity — diagnosis linkage

Medical necessity for listed seating HCPCS codes is supported by the presence of one of the following ICD-10-CM diagnoses

Supported diagnoses: Presence of any single ICD-10-CM code from the enumerated lists (including neurologic, neuromuscular, congenital, paralysis, traumatic amputation, and pressure ulcer codes) supports medical necessity for the associated seating HCPCS codes.

See the ICD-10-CM Diagnosis Codes That Support Medical Necessity tables in the policy for full code lists (chunks 36–74 and 72–91).

inv-67: DME diagnosis support

Medical necessity is supported when the member has one of the enumerated ICD-10-CM diagnoses associated with substantial functional impairment

Functional-impairment diagnoses: Conditions such as spinal cord injury, multiple sclerosis, cerebral palsy, amyotrophic lateral sclerosis, muscular dystrophy, hemiplegia/paraplegia, traumatic amputation, and other listed diagnoses that cause substantial mobility limitation or postural instability support medical necessity for seating and positioning equipment.

Complete diagnosis lists are provided across the ICD-10 sections of the policy (see chunks 36–55, 72–91).

inv-68: Documentation supporting medical necessity

Medical necessity for wheelchair seating is supported when documentation includes:

Diagnosis requirement: At least one ICD-10-CM diagnosis from the policy's listed codes that clinically supports the need for the requested seating or positioning HCPCS code (e.g., E2607/E2608/E2624/E2625 or E2609).n>=1

Include the specific diagnosis code on the claim and in clinical documentation; pressure-ulcer HCPCS codes require billing with the applicable L89.xx code(s).

Custom fabrication documentation: For custom fabricated cushions (E2609, E2617), include a comprehensive written evaluation by a licensed/certified PT or OT that explains why prefabricated seating is insufficient; the evaluator must have no financial relationship with the supplier.

Documentation should reference relevant LCD/LCA guidance where applicable.

inv-69: DME medical necessity alignment

Medical necessity criteria align with Medicare LCD L33312 and supporting ICD-10/HCPCS coding tables; clinical conditions added over time

Alignment with LCD and coding tables: The policy's medical necessity criteria are based on review of HCPCS Level II and ICD-10-CM coding guidance and align with Medicare LCD L33312 and associated Local Coverage Article(s); diagnosis and HCPCS tables have been updated over time to add supported clinical conditions.

Providers should consult the cited LCD/LCA and current HCPCS/ICD-10 resources when preparing documentation and prior authorization requests.

HCPCS Code(s)	Equipment / Description	Rental vs Purchase
Purchase

Equipment / Group	Rental vs Purchase	Notes
Prior authorization requests for these codes should include an ICD-10-CM diagnosis from the document to substantiate medical necessity.

Equipment / Group	Rental vs Purchase	Notes / Source
Coding references are informational; providers should reference current coding guidance for billing and claims submission.

HCPCS Code	Equipment / Description	Rental vs Purchase
Not specified in this segment — prior authorization/medical necessity reviews for E2609 should be supported by one of the ICD-10-CM diagnosis codes listed in the policy.

Component / HCPCS	Rental vs Purchase	Notes / Guidance
Rental vs purchase governed by HCPCS guidance and applicable LCDs/local coverage articles; providers should consult current HCPCS and LCD rules.

Replacement

Replacement — placeholder (inventory item present, no content)

Replacement interval — policy contentNot specified; inventory item present as placeholder only.

ActionRefer to Health Plan prior authorization and rental/purchase rules or LCD guidance for replacement guidance.

Related noteReplacement rules for cushions referenced elsewhere as governed by HCPCS/LCD guidance.

Replacement — placeholder (inventory item present, no content)

Replacement interval — policy contentNot specified; inventory item present as placeholder only.

ActionCheck plan-level administrative policies and LCD for replacement frequency and coverage rules.

Related HCPCSReplacement considerations apply to multiple HCPCS-listed seating components; see billing/rental rules.

Wheelchair seating (E2609) — replacement note (inventory item)

Replacement note for E2609Replacement interval not specified in this policy; HCPCS E2609 (custom fabricated cushion) is listed but no replacement timing provided.

Documentation requirementWhen requesting replacement/custom item, include required PT/OT written evaluation explaining why prefabricated options are insufficient.

ActionFollow Health Plan prior authorization processes and reference LCD/LCA guidance for purchase vs rental and replacement rules.

wheelchair seating — replacement administrative note

Administrative replacement noteCustom fabrication (E2609) requires a comprehensive written evaluation by a licensed/certified PT or OT; evaluator must have no financial relationship with the supplier — include when requesting replacement or new custom cushions.

Prior authorizationPrior authorization is implied for approval of custom items and replacements when medical necessity criteria are met.

DocumentationMaintain clinical records linking diagnosis and justification for replacement in accordance with policy and LCD guidance.

Documentation Requirements

Documentation Required

PT/OT evaluation required for custom fabricated cushions

A comprehensive written evaluation by a licensed/certified PT or OT is required to justify custom fabrication; the evaluation must explain why prefabricated seating is insufficient and the evaluator must have no financial relationship with the supplier.

Evaluation must be documented in writing and retained in the medical record.
Evaluator (PT/OT) must have no financial relationship with the supplier.

Documentation Required

Include one listed ICD-10-CM diagnosis with PA requests

Include one supporting ICD-10-CM diagnosis code from the policy's provided lists with the prior authorization request for the applicable HCPCS seating and positioning codes.

The supporting diagnosis code must come from the policy's enumerated ICD-10-CM tables that correspond to the HCPCS code requested.

Documentation Required

Link the beneficiary's diagnosis to E2607/E2608/E2624/E2625

Document and link the beneficiary's diagnosis to HCPCS E2607, E2608, E2624, or E2625 in submitted clinical records and prior authorization/claim documentation to support medical necessity.

Ensure the clinical record explicitly ties the ICD-10-CM diagnosis to the need for the specific HCPCS item.

Billing Rule

Bill pressure ulcer diagnosis with pressure‑relief seating HCPCS

When billing pressure‑relief seating HCPCS, bill the applicable pressure ulcer ICD-10-CM diagnosis code from the policy's pressure ulcer list together with E2607, E2608, E2624, or E2625 to substantiate medical necessity.

Use the L89.xx series (and other pressure‑ulcer codes listed) as applicable on the claim.

Documentation Required

Submit an enumerated ICD-10-CM code with E2609 requests

Include one of the listed ICD-10-CM diagnosis codes from the policy with prior authorization and claim documentation for HCPCS E2609 to demonstrate medical necessity for custom fabricated seating.

Document the chosen ICD-10-CM code in clinical notes and on the claim for E2609.

Documentation Required

Align clinical justification with LCD L33312 and Article A52505

Provide clinical justification for wheelchair seating equipment requests that aligns with Medicare LCD L33312 and Local Coverage Article A52505 and reference the applicable HCPCS and ICD-10-CM codes listed in this policy when submitting PA/claims.

Reference the cited LCD/LCA and the HCPCS/ICD-10 code tables included in the policy in supporting documentation.

Not Covered / Exclusions

The policy identifies several specific items as not covered when they meet the Not Medically Necessary criteria: powered seat cushions (E2610), the manual wheelchair solid seat insert (E0992), and cushions or accessories that do not meet HCPCS coding criteria or lack PDAC verification (e.g., K0669). These items are listed in the Not Medically Necessary / Not Covered sections and will trigger claim denials unless an exception is documented.

The excerpt provided for this segment does not list other specific DME items or situations that are not covered beyond those explicitly identified in the policy's Not Medically Necessary section. Providers should consult the full policy and any applicable LCDs for a complete list of non-covered items.

Coverage in this policy is diagnosis-driven: requests for many seating and positioning HCPCS codes must be supported by an applicable ICD-10-CM diagnosis from the enumerated lists. If a situation lacks an applicable ICD-10-CM diagnosis from those lists, medical necessity is not supported by the portion of the document provided and the request may be denied.

This document segment concentrates on listing diagnoses that support medical necessity and does not, in the excerpt shown, enumerate additional not-covered DME items or scenarios beyond the established Not Medically Necessary codes. Confirm coverage status against the complete policy and plan-level rules when in doubt.

Per the policy's update history and the Not Medically Necessary codes section, E0992 (manual wheelchair accessory solid seat insert) has been designated not medically necessary following LCD guidance and is therefore not covered unless an exception is specified in the policy.

Definitions & Key Terms

Pressure-relief history — history of prior pressure ulcer increases susceptibility to future skin breakdown

Definition — pressure-relief historyHistory of prior pressure ulcer increases susceptibility to future skin breakdown; prior ulceration reduces tissue strength and the patient is more susceptible to recurrence.

Clinical implicationEvaluators should document past skin breakdown and record method/frequency of pressure relief when prescribing seating systems.

AssessmentConsider incontinence and expected functional changes (e.g., progressive disease, growth) when selecting cushions to avoid systems that previously contributed to breakdown.

Supported diagnosis list — ICD-10-CM Diagnosis Codes That Support Medical Necessity

Supported diagnosis listICD-10-CM Diagnosis Codes That Support Medical Necessity are enumerated in the policy and must be used to substantiate requests for listed HCPCS codes.

ScopeList includes neurologic, neuromuscular, congenital, amputation, pressure ulcer, and degenerative diagnoses (see policy ICD-10 tables).

Provider actionInclude at least one supporting ICD-10-CM code from this list with prior authorization and claims for the related HCPCS codes.

Diagnosis codes that support medical necessity — ICD-10-CM codes enumerated in the policy segment

Representative ICD-10-CM codesExamples include G31.82 (Leigh's disease), G35 (Multiple sclerosis), G61.0 (Guillain-Barre syndrome), G71.01 (Duchenne/Becker muscular dystrophy), G80.0 (Spastic quadriplegic cerebral palsy), G82.21 (Paraplegia, complete), G82.50 (Quadriplegia, unspecified), L89.153 (Pressure ulcer of sacral region, stage 3), Q79.60 (Ehlers-Danlos syndrome), G12.21 (ALS), G20 (Parkinson's disease), E75.25 (Metachromatic leukodystrophy).

UseThese ICD-10-CM codes (and many others listed across the policy tables) support medical necessity for the associated seating HCPCS codes when documented in the medical record.

ActionSelect and document the specific ICD-10-CM code from the policy list on prior authorization requests and claims for the corresponding HCPCS code.

Pressure ulcer diagnosis linkage — specific ICD-10-CM pressure ulcer codes designated to support medical necessity for select HCPCS

Pressure-ulcer ICD-10-CM codes (examples)L89.130, L89.131, L89.132, L89.133, L89.134, L89.140, L89.141, L89.142, L89.143, L89.144, L89.150, L89.151, L89.152, L89.153, L89.154, L89.200, L89.201, L89.202, L89.203, L89.204, L89.210, L89.211, L89.212, L89.213, L89.214, L89.220, L89.221, L89.222, L89.223, L89.224, L89.300, L89.301, L89.302, L89.303, L89.304, L89.310, L89.311, L89.312.

Linkage requirementAn applicable pressure ulcer ICD-10-CM diagnosis must be billed with HCPCS codes E2607, E2608, E2624, or E2625 to support medical necessity for pressure-relief seating.

Provider actionEnsure the specific L89.xx code corresponding to the patient's pressure ulcer is included on the claim and in clinical documentation when submitting for these HCPCS codes.

E2609 — HCPCS code referenced for which certain ICD-10-CM codes support medical necessity

E2609 — HCPCS codeE2609 (Custom fabricated wheelchair seat cushion) is referenced in the policy as supported when accompanied by one of the ICD-10-CM diagnoses enumerated for E2609.

Diagnosis requirementMedical necessity for E2609 is supported when any single ICD-10-CM diagnosis from the policy's listed codes (chunks 72–91) is documented and linked to the request.

Provider actionInclude the specific ICD-10-CM code from the E2609 support list on prior authorization requests and in clinical records when requesting E2609.

Documentation & References

Documentation Required

Reference HCPCS Level II, ICD-10-CM, LCD L33312 and A52505

This policy is based on HCPCS Level II (2024), ICD-10-CM (2024), LCD L33312, and Local Coverage Article A52505; providers should reference these source documents when documenting medical necessity and preparing prior authorization requests.

Use the referenced code sets and Medicare coverage guidance when preparing documentation.

Note

Coverage subject to plan documents, exclusions, and law

Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions, and limitations of the member's coverage documents, and to state and federal law; providers must follow plan-level administrative policies and procedures.

Inconsistencies between this policy and legal/regulatory requirements are resolved in favor of law/regulation.

OpenPayer

Wheelchair Seating - Coverage Criteria and Medical Necessity

Coverage Criteria

Coding

Provider Actions / Authorization & Billing

Medical Necessity

Rental & Purchase Rules

Replacement

Documentation Requirements

Not Covered / Exclusions

Background

Definitions & Key Terms

Documentation & References