Clinical Policy: Wheelchair Seating

Coverage Summary

This policy (Policy/Reference: CP.MP.99) covers wheelchair seating cushions and accessories for members/enrollees. Status: CURRENT. Date of last review: 03/24. This excerpt is part 1 of 4 of the full policy and the coverage stance is mixed (some HCPCS codes and indications are covered while others are not). The document defines medical necessity criteria, not-medically-necessary exclusions, and links to LCD L33312 for coding/ICD-10 mapping.

Key facts

Policy NumberCP.MP.99

SubjectWheelchair seating cushions and accessories

StatusCURRENT

Last review03/24

PartPart 1 of 4

Medical-Necessity Criteria

Medically Necessary

Special wheelchair seating cushions and accessories are medically necessary when the following criteria are met:

General use seat/back

HCPCS codes: E2601, E2602, E2611, E2612

Skin-protection seat cushion

HCPCS codes: E2603, E2604, E2622, E2623
One of
- Pressure ulcer: Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface

Coding

Medically necessary - Seat cushionsHCPCSCovered

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	Skin protection wheelchair seat cushion, width less than 22 inches, any depth
E2604	Skin protection wheelchair seat cushion, width 22 inches or greater, any depth
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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Medically necessary - Back cushionsHCPCSCovered

E2611	General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware
E2612	General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware
E2613	Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware
E2614	Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware
E2615	Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware
E2616	Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware
E2617	Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
E2620	Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware
E2621	Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware

Medically necessary - Positioning accessoriesHCPCSCovered

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 strap, including any type mounting hardware
E0966	Manual wheelchair accessory, headrest extension, each
E1028	Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

Miscellaneous / AccessoriesHCPCSCovered

A9900	Miscellaneous DME supply, accessory, and/or service component of another HCPCS code
E2231	Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware
E2291	Back, planar, for pediatric size wheelchair including fixed attaching 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

Not medically necessary (listed)HCPCSNot Covered

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

Transport chair related (not covered)HCPCSNot Covered

E1037	Seat cushion for transport chair (listed as not medically necessary in policy text)
E1038	Back cushion for transport chair (listed as not medically necessary in policy text)

HCPCS codes with no diagnosis-code restrictionsHCPCS

E0955	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)
E2601	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)
E2602	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)
E2611	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)
E2612	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)
E2619	undefined in this excerpt (HCPCS listed as having no diagnosis-code restrictions)

HCPCS codes referenced for ICD-10 additions/removals (mapping group - informational)HCPCS

E0953	Positioning accessory; referenced in ICD-10 mapping updates
E0956	referenced in ICD-10 mapping updates
E0957	referenced in ICD-10 mapping updates
E0960	referenced in ICD-10 mapping updates
E2603	referenced in ICD-10 mapping updates
E2604	referenced in ICD-10 mapping updates
E2605	referenced in ICD-10 mapping updates
E2606	referenced in ICD-10 mapping updates
E2607	referenced in ICD-10 mapping updates
E2608	referenced in ICD-10 mapping updates

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ICD-10 codes listed in this excerpt (diagnosis codes referenced for coverage mapping)ICD-10

S88.022D	Partial traumatic amputation at knee level, left lower leg, subsequent encounter
S88.022S	Partial traumatic amputation at knee level, left lower leg, sequela
S88.029A	Partial traumatic amputation at knee level, unspecified lower leg, initial encounter
S88.029D	Partial traumatic amputation at knee level, unspecified lower leg, subsequent encounter
S88.029S	Partial traumatic amputation at knee level, unspecified lower leg, sequela
S88.911A	Complete traumatic amputation of right lower leg, level unspecified, initial encounter
S88.911D	Complete traumatic amputation of right lower leg, level unspecified, subsequent encounter
S88.911S	Complete traumatic amputation of right lower leg, level unspecified, sequela
S88.912A	Complete traumatic amputation of left lower leg, level unspecified, initial encounter
S88.912D	Complete traumatic amputation of left lower leg, level unspecified, subsequent encounter

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Provider Actions

Documentation Required

Comprehensive evaluation required for custom fabrication

A comprehensive, written evaluation by a licensed/certified medical professional (PT or OT) must clearly explain why a prefabricated seating system is not sufficient; the evaluator must have no financial relationship with the supplier.

Codes: E2609, E2617
Evaluator must have no financial relationship with the supplier

Documentation Required

Diagnosis support required

Use an ICD-10-CM diagnosis from the listed supporting codes when requesting skin-protection cushions, positioning cushions, or positioning accessories; pressure ulcer history or listed neurological/musculoskeletal diagnoses must be documented.

Use the ICD-10-CM supporting codes listed in the policy when requesting skin-protection/positioning items

Background

Background clinical considerations: clinicians should consider progressive disease (e.g., MS or ALS) and anticipate changing needs over time, and account for growth in pediatric patients when ordering chairs or equipment. Evaluating providers must ascertain the individual’s level of bowel and bladder control, document any history of skin breakdown (prior pressure ulcers increase future risk), and must record the method and frequency of pressure relief when prescribing seating systems so the new system does not remove previously used pressure-relief features.

Definitions / short glossary:

- HCPCS: Healthcare Common Procedure Coding System Level II codes used to identify DME, accessories, and supplies. (See HCPCS tables in policy.)

- LCD L33312: Local Coverage Determination “Wheelchair Seating” used as the source for mapping ICD-10 codes to HCPCS codes and referenced throughout the policy.

Medicare Determinations

Name	Number	Effective / Notes
Wheelchair Seating	L33312	2015-10-01 (revised 2020-01-01; article revised 2023-12-20 per references)

Revision History

09/15created

Policy created; therapist reviewed (initial creation entry in revision log).

09/16-09/17revised

Moved E0992 to not medically necessary codes per LCD and updated references/ICD-10 additions.

09/19-09/20clarified

Typo corrected clarifying K0860-K0864 range and codes in range listed explicitly; ICD-10 10/1/20 updates applied (G11/G71 replacements and subcategories).