CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Standers and Power-Assisted (Dynamic) Standing Components for Wheelchairs

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Identifies the clinical information MassHealth needs to determine medical necessity and prior authorization requirements for static standers, tilt tables, and power-assisted standing components for wheelchairs.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyStanders and Power-Assisted (Dynamic) Standing Components for Wheelchairs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 6, 2019

Next Review DateN/A

Key ActionSubmit prior authorization requests through the appropriate MassHealth process with the required prescription and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 minMinimum therapeutic standing duration

5 days/week

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Standers and Power-Assisted (Dynamic) Standing Components for Wheelchairs

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

Know when Massachusetts Executive Office of Health and Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyStanders and Power-Assisted (Dynamic) Standing Components for Wheelchairs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 6, 2019

Next Review DateN/A

Key ActionSubmit prior authorization requests through the appropriate MassHealth process with the required prescription and supporting clinical documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30 minMinimum therapeutic standing duration

5 days/week

Minimum standing frequency

60 min/dayOptimal bone health standing time

90 daysPurchase authorization deadline

2019-12-06Effective date

2009-02-15Superseded policy date

Coverage Criteria

Static Standers and Tilt Tables

Covered when ALL of the following criteria are met:

ALL of the following

The member is unable to stand or ambulate independently due to conditions such as, but not limited to, neuromuscular or congenital disorders, including acquired skeletal abnormalities.
ONE of the following
- The member is at high risk for lower-limb or trunk contracture(s).
- The member has non-fixed contracture(s) that have not improved with other interventions, such as stretching, splinting, serial casting, medications, or other modalities.
The alignment of the member's lower extremity is such that the foot, ankle, knee, and hip can tolerate a standing or upright position.
The member has demonstrated the ability to tolerate standing for a therapeutic length of time during a documented trial period.>= 30 minutes at one time
The member has improved or maintained status in mobility, ambulation, or physiologic symptoms with use of the selected device and is able to follow a home therapy program incorporating use of the device.
There is a prescribed home standing program outlining use of the requested device that can be carried out by the member safely and independently or with the assistance of a caregiver.

Power-Assisted Dynamic Standing Components

Covered when ALL static-stander criteria above and each of the following additional criteria are met:

ALL of the following

The member meets all criteria for static standers and tilt tables.
There are evidence-based reasons and documented clinical justification explaining why a power-assisted standing component will meet the member's medical needs and why a static stander or tilt table will not meet those needs.
The member has additional symptoms, such as pain or increased tone, requiring standing throughout the day to alleviate or reduce those symptoms, and documentation demonstrates why a static stander or tilt table will not address those medical needs.
The member has demonstrated the ability to use the requested device safely, with proper safety awareness, and independently, without physical assistance or cueing, and is able to perform a prescribed home standing program independently.

Noncoverage and Medical Necessity Exclusions

Standers and power-assisted standing components are not medically necessary, or are not covered, when ANY of the following circumstances applies:

ANY of the following

The equipment is non-medical equipment, such as a glider, that is not used primarily and customarily for a medical purpose and is generally useful in the absence of illness, injury, or disability.
The documentation does not support that the member is able to achieve an evidence-based medical benefit from using the stander, including when the member cannot tolerate standing for the therapeutic length of time.
The anticipated therapeutic benefits of standing can be achieved through less costly alternatives that are comparable in effect, available, and suitable for the member, including more conservative options such as therapeutic exercises, positioning, ambulation, orthotics, other adaptive DME, medication, or diet.
The member has not demonstrated the ability to use a power-assisted standing component safely and independently, including when the member lacks proper safety awareness or requires physical assistance or cueing.

Under the MassHealth Durable Medical Equipment program, equipment must be used primarily and customarily for a medical purpose and must not be generally useful in the absence of illness, injury, or disability. Non-medical equipment, such as a glider, is therefore not covered as DME.

A power-assisted standing component is not medically necessary when it is requested solely for the convenience of the caregiver rather than to address the member's medical needs.

Coverage is not supported when documentation does not show that the member can achieve the evidence-based medical benefit of standing, including when the member cannot tolerate the required therapeutic standing duration of at least 30 minutes at one time.

Coverage is excluded when the anticipated therapeutic benefits can be achieved through less costly alternatives that are comparable in effect, available, and suitable for the member. Examples of more conservative alternatives include therapeutic exercises, positioning, ambulation, orthotics, other adaptive DME, medication, and diet.

A power-assisted standing component is not medically necessary when the member cannot use it safely and independently. This includes inadequate safety awareness or the need for physical assistance or cueing.

Medical Necessity Criteria

Static Stander and Tilt Table Criteria

Static standers and tilt tables are covered when the member meets all of the following functional, clinical, tolerance, benefit, and home-program requirements:

Static stander and tilt table medical necessity: The member is unable to stand or ambulate independently; has high risk for lower-limb or trunk contractures or non-fixed contractures that have not improved with other interventions; has lower-extremity alignment compatible with standing; has demonstrated therapeutic standing tolerance during a documented trial; has improved or maintained mobility, ambulation, or physiologic symptoms with the selected device; and can safely follow a prescribed home standing program independently or with caregiver assistance.minimum 30 minutes or more at one time during a documented trial period

Power-Assisted Dynamic Component Criteria

A power-assisted standing component requires the static stander or tilt table criteria plus all of the following additional requirements:

Power-assisted dynamic component medical necessity:

Therapeutic Standing Parameters

Therapeutic standing tolerance

Minimum toleranceAt least 30 minutes at one time

Evidence requiredThe member must demonstrate this tolerance during a documented trial period

Clinical purposeThe duration must be sufficient for therapeutic standing

Standing duration for high muscle tone

Minimum durationAt least 30 minutes at a time

FrequencyOnce a day

Clinical indicationImprovement in high muscle tone

Prior Authorization and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for standers and power-assisted (dynamic) standing components. The request must be submitted by a MassHealth DME provider, and MassHealth reviews it based on medical necessity; consult applicable MassHealth regulations, coverage tools, and managed-care plan policies as appropriate.

The DME provider is responsible for submitting the PA request.
Approval is subject to applicable coverage, service, and program conditions.

Denial Risk

PA Approval Does Not Guarantee Payment

MassHealth approval of a PA request does not guarantee payment. Payment remains subject to all general MassHealth conditions, including member eligibility, other insurance, and program restrictions.

Verify eligibility, other insurance, and applicable program restrictions before dispensing or billing.

Clinical Background

Standers and related standing devices support therapeutic upright positioning for individuals who cannot independently stand or ambulate. They may provide mobility, musculoskeletal, physiologic, and functional benefits when used as part of a prescribed home-based standing program.

Key Definitions

Stander

Device typeMechanical device

Primary functionAssists a person in attaining and maintaining an upright position

PurposeTherapeutic standing

Therapeutic standing

DefinitionStanding performed using a supported standing device for therapeutic purposes

Supported devicesStatic standers or tilt tables

Additional deviceA power-assisted standing component in certain wheelchairs

Rental and Purchase Rules

Equipment	Rental or purchase	Rule
Standers	Purchase	MassHealth pays for purchase only after the DME provider obtains a written prescription signed by a licensed practitioner and submits the prior authorization request no later than 90 calendar days from the prescription date. The stander must have been successfully used on a trial basis in an inpatient, outpatient, or school setting.

Required Documentation

Documentation Required

Support purchase with successful trial and clinical documentation

For purchase documentation, show that the stander was successfully used on a trial basis in an inpatient, outpatient, or school setting. Also document medical necessity, failure of less costly alternatives, therapeutic standing tolerance, the prescribed home program, access to alternative equipment settings, and home accommodation.

Successful inpatient, outpatient, or school trial
Failure of less costly alternatives comparable in effect
Safe therapeutic standing for a minimum of 30 minutes at a time
Prescribed home-based therapeutic standing program and tolerance
Member’s access to equipment in an alternative setting
Home can accommodate the equipment

Prior Authorization

Provide a valid prescription and submit PA on time

Include a written prescription signed by a licensed practitioner on the prescriber’s prescription pad, letterhead, or a Region A DMERC certificate of medical necessity completed according to applicable instructions. Submit the PA request no later than 90 calendar days from the prescription date.

Excluded Items and Uses

The following equipment or uses are not covered or are not medically necessary: non-medical equipment, including a glider; a power-assisted standing component requested solely for caregiver convenience; equipment for which a less costly, comparable, available, and suitable conservative alternative can achieve the anticipated therapeutic benefit; and a stander when the member cannot tolerate the therapeutic standing duration or the documentation does not support an evidence-based medical benefit. A power-assisted component is also excluded when the member cannot use it safely and independently or requires physical assistance or cueing.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyStanders and Power-Assisted (Dynamic) Standing Components for Wheelchairs

Policy CodePolicy N/A

Change TypeNo material change

Effective DateDec 6, 2019

Next Review DateN/A

Key ActionSubmit prior authorization requests through the appropriate MassHealth process with the required prescription and supporting clinical documentation.

SourceLink

On This Page

The power-assisted standing component is requested solely for the convenience of the caregiver.

The member has evidence-based clinical justification for why the power-assisted component will meet the member's medical needs and why a static stander or tilt table will not; has additional symptoms such as pain or increased tone requiring standing throughout the day that the component will address; and has demonstrated proper safety awareness and the ability to use the device safely and independently without physical assistance or cueing while independently performing the prescribed home standing program.

Standing duration for bone mineralization and density

Standing time60 minutes per day

Expected resultOptimal benefit

Clinical purposeImprovement in or maintenance of bone mineralization and density

Standing frequency

Minimum frequencyFive days per week

Program settingHome-based supported standing program

PurposeRequired to achieve the described therapeutic benefits

Prescription-to-PA submission interval

Submission deadlineNo later than 90 calendar days from the prescription date

Prescription requirementWritten prescription signed by a licensed practitioner

Submission recipientMassHealth agency

Unsupported block type: documentation

Documentation Required

Include Clinical Assessment and Treatment Documentation

The clinical record must identify the member and include a recent comprehensive history and physical examination, diagnosis-related details, treatment needs, and functional and physical findings supporting the request.

Include the member’s name and address, medical condition, age at diagnosis, prognosis, and co-morbid conditions.
Include strength, range of motion, tone, sensation, balance, ADLs, IADLs, and functional status.
Include the prescribed home-based therapeutic standing program and documentation that the member can tolerate it.

Unsupported block type: documentation

Unsupported block type: prior_auth

Denial Risk

Avoid Clinical Documentation Denials

Requests are at risk of denial when the record does not establish the expected evidence-based medical benefit, the member’s ability to tolerate therapeutic standing, failure of comparable alternatives, or safe and independent use of the equipment.

Document therapeutic standing for at least 30 minutes at a time; shorter periods may not produce comparable muscle or bone benefits.
For dynamic components, document safety awareness and independent use without physical assistance or cueing.
Do not request equipment solely for caregiver convenience.

Billing Rule

Non-Medical Equipment Is Not Covered

Non-medical equipment, including a glider, is not covered as MassHealth DME because covered equipment must be used primarily and customarily for a medical purpose and not be generally useful without illness, injury, or disability.

Confirm that the requested item is medical equipment and supports a documented therapeutic purpose.

Denial Risk

Complete the PA Request Before Submission

An incomplete or improperly submitted PA request may not be reviewable. The MassHealth DME provider must submit the required prescription, complete clinical documentation supporting medical necessity, and use the specified PA submission pathway.

Include the signed prescription, letter of medical necessity, clinical assessment, alternative-treatment documentation, access and home-accommodation documentation, and any dynamic-component documentation.
Submit through the LTSS Provider Portal using the appropriate request type, or use the PA-1 form with pertinent attachments.

Durable medical equipment

Primary useEquipment primarily and customarily used for a medical purpose

General usefulnessNot generally useful in the absence of illness, injury, or disability

Coverage exampleNon-medical equipment, such as a glider, is not covered as DME

Written prescription signed by a licensed practitioner
Acceptable prescription format
PA submission within 90 calendar days of the prescription date